Transient severe haemodynamic disturbance during radical nephrectomy: a probable catecholamine surge.

Catecholamine surge and haemodynamic derangements are normally expected during the surgery for pheochromocytoma and benign functioning adrenal tumours. This male patient in his 50s underwent radical nephrectomy for renal cell carcinoma. The patient had no comorbidities. Three hours into the surgery, during electrocauterisation of the upper pole of the kidney, the patient's blood pressure unexpectedly spiked to 180/110 mm Hg, which was immediately followed by a decrease in heart rate to 35-38 beats/min. The surgeons were instructed to briefly halt the surgical manipulation. The blood pressure returned to the pre-surge level within 30-45 s. The surgery was completed without further complications, and the patient had an uneventful recovery. The episode is suggestive of the probability that the electrocauterisation of the upper pole of the kidney led to the accidental cauterisation of the adrenal gland, resulting in a transient catecholamine surge, increase in blood pressure and reflex bradycardia suggesting norepinephrine release. Treating bradycardia with atropine in such situations can exacerbate the effects of catecholamines and lead to dangerous tachyarrhythmias. The case report highlights the importance of vigilant monitoring during electrocauterisation of the upper pole of the kidney, invasive arterial blood pressure monitoring in detecting and recording such occurrences and cautiously selecting a treatment plan.

Preoperative aspirin and anticoagulants do not affect partial nephrectomy bleeding.

INTRODUCTION: Studies have reached mixed conclusions on the role of antiplatelet and anticoagulant agents on postoperative complications of partial nephrectomies. This study examines whether preoperative anticoagulation use affected the risk of hemorrhagic complications after partial nephrectomy. MATERIALS AND METHODS: This is a retrospective chart review of all partial nephrectomies performed between 2017 and 2022 at a single institution. For each operation, preoperative data was gathered on whether the patient was on anticoagulation, the type and dose of anticoagulation, and how many days the anticoagulation was held preoperatively. Bivariate analyses for continuous measures were performed using Student's t-tests when there were two comparison groups and ANOVA models when there were more than two comparison groups and Chi-Square tests were used for categorical variables, with Fisher's Exact being used when expected cell counts were small. RESULTS: In this study, warfarin was held for an average of 5.43 days, clopidogrel was held for an average of 6.60 days, aspirin was held for an average of 7.65 days, and direct oral anticoagulants (DOACs) were held for an average of 4.00 days. There was no significant difference in hemoglobin (Hb) change, rate of intraoperative transfusion, postoperative transfusion, bleeding complication, pseudoaneurysm rate, or additional bleeding processes between patients on prior anticoagulation therapy and those not on therapy. There was no significant difference in intraoperative or postoperative outcomes based on history of aspirin use and continuation of aspirin through the surgery. While estimated blood loss appeared statistically significant initially, this difference was accounted for by the covariates of comorbidities, RENAL score, surgical approach, and type of renorrhaphy. Overall, there was no difference in complication rate based solely on aspirin use or continuation of aspirin through surgery. CONCLUSIONS: No difference in complication rate of partial nephrectomy was determined to be solely due to prior use of anticoagulation or aspirin use alone with appropriate cessation of anticoagulation preoperatively. Overall, patients on anticoagulation are not at a higher risk of intraoperative or postoperative bleeding complications when undergoing partial nephrectomy.

Renal artery pseudoaneurysm following robot assisted nephron sparing surgery: two case reports.

BACKGROUND: Renal artery pseudoaneurysm following partial nephrectomy is a rare entity, the incidence of this entity is more common following penetrating abdominal injuries, percutaneous renal interventions such as percutaneous nephrostomy(PCN) or Percutaneous nephrolithotomy (PCNL). Although rare, renal artery pseudoaneurysm can be life threatening if not managed timely, they usually present within two weeks postoperatively with usual presenting complains being gross haematuria, flank pain and/or anaemia. CASE PRESENTATION: We report case of two female patients 34 and 57 year old respectively of South Asian ethnicity, presenting with renal artery pseudoaneurysm following left sided robot assisted nephron sparing surgery for interpolar masses presenting clinically with total, painless, gross haematuria with clots within fifteen days postoperatively and their successful treatment by digital subtraction angiography and coil embolization. CONCLUSION: Renal artery aneurysm is a rare fatal complication of minimally invasive nephron sparing surgery however considering the preoperative and intraoperative risk factors for its development and prompt suspicion at the outset can be life saving with coil embolization of the bleeding arterial aneurysm.

Development and validation of metrics for a new RAPN training model.

Robot-assisted partial nephrectomy (RAPN) is a complex and index procedure that urologists need to learn how to perform safely. No validated performance metrics specifically developed for a RAPN training model (TM) exist. A Core Metrics Group specifically adapted human RAPN metrics to be used in a newly developed RAPN TM, explicitly defining phases, steps, errors, and critical errors. A modified Delphi meeting concurred on the face and content validation of the new metrics. One hundred percent consensus was achieved by the Delphi panel on 8 Phases, 32 Steps, 136 Errors and 64 Critical Errors. Two trained assessors evaluated recorded video performances of novice and expert RAPN surgeons executing an emulated RAPN in the newly developed TM. There were no differences in procedure Steps completed by the two groups. Experienced RAPN surgeons made 34% fewer Total Errors than the Novice group. Performance score for both groups was divided at the median score using Total Error scores, into HiError and LoError subgroups. The LowErrs Expert RAPN surgeons group made 118% fewer Total Errors than the Novice HiErrs group. Furthermore, the LowErrs Expert RAPN surgeons made 77% fewer Total Errors than the HiErrs Expert RAPN surgeons. These results established construct and discriminative validity of the metrics. The authors described a novel RAPN TM and its associated performance metrics with evidence supporting their face, content, construct, and discriminative validation. This report and evidence support the implementation of a simulation-based proficiency-based progression (PBP) training program for RAPN.

Renal anatomical classification systems cannot predict the occurrence of vascular complications after partial nephrectomy.

OBJECTIVES: To determine the relationship between renal tumor complexity and vascular complications after partial nephrectomy using PADUA, RENAL, and ZS scores. METHODS: Between January 2007 and December 2018, a total of 1917 patients with available cross-sectional imaging were enrolled in the study. Logistic regressions were used to identify independent predictors of vascular complications. RESULTS: Of 1917 patients, 31 (1.6%) developed vascular complications, including 10 females and 21 males. The high-complexity category was significantly associated with a decreased risk of vascular complication in PADUA (OR = 0.256; 95%CI = 0.086-0.762; P = 0.014) and ZS score (OR = 0.279; 95%CI = 0.083-0.946; P = 0.040). Laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were independent risk factors for vascular complications. Meanwhile, the incidence was significantly reduced in the recent 4 years in the high score tumor group alone in PADUA (0.2% [1/474] vs. 2.2% [3/139], P = 0.038) and ZS score (0.2% [1/469] vs. 2.7% [3/112], P = 0.024). In the first 8 years, laparoscopic partial nephrectomy and robot-assisted laparoscopic partial nephrectomy were the only two independent risk factors for vascular complications. In the recent 4 years, only the high-complexity category was significantly associated with a decreased risk of vascular complication in the PADUA score (OR = 0.110; 95%CI = 0.013-0.938; P = 0.044). CONCLUSION: The renal anatomic classification system cannot predict the occurrence of vascular complications after partial nephrectomy.

Comparison of intravesical chemotherapy regimens after radical nephroureterectomy for upper tract urothelial carcinoma and analysis of risk factors for postoperative recurrence.

OBJECTIVE: Upper tract urothelial carcinoma (UTUC) is a relatively rare but aggressive type of urologic cancer that includes renal pelvic tumors and ureteral tumors with a poor prognosis. Full-length nephroureterectomy plus sleeve bladder resection is the standard treatment for the disease, but patients are prone to recurrence of bladder tumors after surgery. Intravesical infusion therapy is the main means to prevent the recurrence and progression of bladder cancer. Epirubicin and gemcitabine are widely used in clinical practice as first-line or salvage therapy for intravesical chemotherapy; however, the efficacy of these agents is rarely discussed. The purpose of this study was to investigate the effects of epirubicin and gemcitabine on the occurrence of bladder cancer after radical nephroureterectomy for UTUC and to analyze the risk factors affecting the recurrence of postoperative bladder cancer. PATIENTS AND METHODS: A total of 215 patients with diagnosed UTUC and treated in our hospital from June 2019 to August 2021 were retrospectively selected as the research subjects, and they were divided into an observation group (120 cases) and a control group (95 cases) according to different treatment methods. The patients in the control group were treated with epirubicin, while those in the observation group received gemcitabine. All patients were followed up by telephone or outpatient examination for 12 months to record the occurrence of adverse reactions. The occurrence of bladder cancer was recorded at 3 months, 6 months, and 12 months after the surgery. According to the occurrence of bladder cancer after surgery, the patients were divided into a bladder cancer group (63 cases) and a non-bladder cancer group (152 cases). Multivariate Logistic regression analysis was used to analyze the risk factors of bladder cancer after surgery. RESULTS: The total incidence of adverse reactions in the control group was 49.47%, which was higher than that in the observation group with 15.00% (p<0.01). The incidence of bladder tumors in the observation group and the control group was 0.00% and 2.11% at 3 months, 5.00% and 8.42% at 6 months, 13.33% and 15.79% at 12 months, without significant difference (p>0.05). After 12 months of perfusion, the levels of acidic fibroblast growth factor (aFGF), basic fibroblast growth factor (bFGF), and vascular endothelial growth factor (VEGF) in the two groups were significantly lower than those before perfusion (p<0.05). In the observation group, the levels of these three factors were slightly decreased compared with those in the control group, without a significant difference (p>0.05). Between the bladder cancer and non-bladder cancer groups, there were significant differences in tumor location, number of lesions, tumor stage, preoperative ureteral examination, and preoperative history of bladder cancer (p<0.05). The above indexes were all risk factors for postoperative bladder cancer (p<0.05). CONCLUSIONS: Epirubicin and gemcitabine reduced the occurrence of bladder cancer and effectively inhibited tumor angiogenesis after radical nephroureterectomy for UTUC. The tumor location, number of lesions, tumor stage, preoperative ureteral examination, and preoperative history of bladder cancer were risk factors for postoperative bladder cancer.

How effective is nephrectomy in curing hypertension in children with unilateral poorly functioning kidney? A systematic review.

PURPOSE: Some children with hypertension (HTN) have unilateral poorly functional kidney (PFK). This provides an opportunity for the clinician to cure the HTN by removal of the PFK, thereby avoiding the problems of long-term medication. However, there is sparse data in children regarding the effect of PFK nephrectomy on curing HTN. In this review, we analysed the etiology of PFK causing HTN and the effectiveness of nephrectomy in curing HTN in children. METHODS: We searched the databases to identify papers between January 2000 to December 2020 pertaining to children with PFK and HTN who underwent nephrectomy. Outcome analyzed was the resolution of HTN following nephrectomy. Duplicate publications, review articles and incomplete articles were excluded. Meta-analysis of heterogeneity was reported with I2statistics. Forest plot was constructed to compare the pooled prevalence of HTN resolution. RESULTS: Five articles with 88 patients were included. Majority (43%) of PFK were due to the unilateral atrophic kidney with or without vesicoureteral reflux (VUR); ureteropelvic junction obstruction and multicystic dysplastic kidney together accounted for 35% of cases and renovascular pathology for 22% of cases. With a follow-up of 1.5 to 3.3 years, nephrectomy was effective to cure HTN in 65.9% (95% CI 55-75%) children. CONCLUSIONS: In children with HTN and a unilateral PFK, nephrectomy cured the HTN in two-thirds of children. Unilateral atrophic kidney due to VUR was the most common cause of PFK. An increase in the utilisation of laparoscopy was observed in recent publications, hence laparoscopic nephrectomy may be considered a first choice of treatment in these children.

Predictive factors of renal function after robot-assisted partial nephrectomy in clinical T1b tumors.

Robot-assisted partial nephrectomy (RAPN) has been shown to be a safe and effective method for treatment of small renal tumors, including clinical T1b renal cell carcinoma (RCC); however, the impact of RAPN for cT1b renal tumors on renal function is not well understood. In this retrospective study, 50 patients who underwent RAPN for cT1b renal tumors were evaluated for pre- and post-operative renal function and perioperative clinical factors. Renal function was assessed using the estimated glomerular filtration rate (eGFR) at baseline and on postoperative days (POD) 1, 7, 30, and 180.A significant renal functional decline was defined as ≥ 15% reduction in eGFR at POD180 compared with eGFR at baseline. Logistic regression analyses were used to identify risk factors for renal function decline, including age, sex, RENAL nephrometry score, operative time, and estimated blood loss. The median patient age was 62 years, and the median tumor diameter and RENAL nephrometry score were 44 mm (IQR 43-50) and 8 (IQR 7-9), respectively. Of these patients, 16 (36%) showed a significant renal functional decline at POD 180. In the multivariate analysis, the L component of the RENAL nephrometry score and an estimated blood loss of 200 mL or more were identified as significant risk factors for renal functional decline. These findings suggest that the preoperatively definable L component of the RENAL nephrometry score and intraoperative blood loss, which may be modifiable factors, play significant roles in post-RAPN renal function decline.

Management of Nontraumatic Spontaneous Renal Hemorrhage (Wünderlich Syndrome) through Robotic-Assisted Laparoscopic Nephrectomy: A Case Series.

BACKGROUND Wünderlich syndrome (WS) is a rare diagnosis of nontraumatic spontaneous renal hemorrhage into the subcapsular, perirenal, or pararenal spaces. Prompt and effective intervention is necessary for an accurate pathological diagnosis and preservation of life. In the current literature, open surgery is the primary option when conservative treatment fails, but there can be serious trauma and corresponding consequences. Herein, we present 3 cases of Wünderlich syndrome managed by robot-assisted laparoscopic nephrectomy via a retroperitoneal approach. CASE REPORT Patient 1 was a 44-year-old woman with right flank pain for 6 h. Patient 2 was a 53-year-old woman with a history of diabetes who had pain in her right flank pain and nausea for 1 day. Patient 3 was a 45-year-old man with left flank pain for 1 day. All cases of WS were confirmed by CT. All 3 patients were treated with retroperitoneal robot-assisted nephrectomy after conservative treatment failed. Pathological examination confirmed that patient 1 had angiomyolipoma, and patients 2 and 3 had renal clear cell carcinoma. At the 9-month follow-up, renal function was good and no evidence of recurrence or metastasis has been detected. CONCLUSIONS These cases have highlighted the importance of the clinical history and imaging findings in the diagnosis of Wünderlich syndrome, and show that rapid management can be achieved using robot-assisted laparoscopic nephrectomy. However, it is crucial to have a skilled surgical team and adequate preoperative preparation.

The survival benefit of metastasectomy for metastatic non-clear cell renal cell carcinoma: a retrospective cohort study.

PURPOSE: The aim of this study was to explore the benefit the metastasectomy for patients with metastatic non-clear cell carcinoma (non-ccRCC). METHODS: This study enrolled 120 patients with confirmed metastatic non-ccRCC from the RCC database of our center from 2008 to 2021. Patients without metastasectomy were grouped as radical nephrectomy without metastasectomy patients. The clinical outcomes included overall survival (OS) and progression-free survival (PFS). Cox regression and Kaplan-Meier analyses were used to assess potential factors that predict clinical benefits from metastasectomy. RESULTS: A total of 100 patients received radical nephrectomy alone, while the remaining 20 patients underwent both radical nephrectomy and metastasectomy. There was no significant difference in age between the two groups. Out of 100 patients who underwent radical nephrectomy, 60 were male, and out of 20 patients who had both radical nephrectomy and metastasectomy, 12 were male. Patients who underwent systemic therapy plus radical nephrectomy and metastasectomy had significantly better PFS (27.1 vs. 14.0, p = 0.032) and OS (67.3 vs. 24.0, p = 0.043) than those who underwent systemic therapy plus radical nephrectomy alone. Furthermore, for patients without liver metastasis (n = 54), systemic therapy plus radical nephrectomy and metastasectomy improved both PFS (p = 0.028) and OS (p = 0.043). Similarly, for patients with metachronous metastasis, systemic therapy plus radical nephrectomy and metastasectomy improved both PFS (p = 0.043) and OS (p = 0.032). None of the patients experienced serious perioperative complications (Clavien-Dindo Classification ≥ III grade). CONCLUSION: Metastasectomy in patients with metastatic non-ccRCC may provide clinical benefits in terms of improved PFS and OS, especially in patients without liver metastasis and those with metachronous metastasis.

Assessing the perioperative outcomes of abdominal drain omission after robot-assisted partial nephrectomy.

The study aimed to evaluate the impact of abdominal drain placement (vs. omission) on perioperative outcomes of robot-assisted partial nephrectomy (RAPN), focusing on complications, time to canalization, deambulation, and pain management. A prospectively-maintained institutional database was queried to get data of patients who underwent RAPN for renal masses between January 2018 and May 2023 at our Institution. Baseline, surgical, and postoperative data were collected. Retrieved patients were stratified based upon placement of abdominal drain (Y/N). Descriptive analyses comparing the two groups were conducted as appropriate.77 After adjusting for potential confounders, a logistic regression analysis was conducted to evaluate significant predictors of any grade and "major" complications. 342 patients were included: 192 patients in the "drain group" versus 150 patients in the "no-drain" group. Renal masses were larger (p < 0.001) and at higher complexity (RENAL score, p = 0.01), in the drain group. Procedures in the drain group had statistically significantly longer operative time, ischemia time, and higher blood loss (all p-values < 0.001). The urinary collecting system was more likely involved compared to the no-drain group (p = 0.01). At multivariate analysis, abdominal drainage was not a significant predictor of any grade (OR 0.79, 95%CI 0.33-1.87) and major postoperative complications (OR 3.62, 95%CI 0.53-9.68). Patients in the drain group experienced a statistically significantly higher hemoglobin drop (p < 0.01). Moreover, they exhibited statistically significant higher paracetamol consumption (p < 0.001) and need for additional opioids (p = 0.02). In summary, the study results suggest the safety of omitting drain placement and remark on the need for personalized decision-making, which considers patient and procedural factors.

Preoperative three-dimensional modelling and virtual reality planning aids nephron sparing surgery in a child with bilateral Wilms tumour.

Bilateral Wilms tumour (BWT) is a surgically challenging condition. Virtual reality (VR) reconstruction aids surgeons to foresee the anatomy ahead of Nephron Sparing Surgery (NSS). Three-dimensional (3D) visualisation improves the anatomical orientation of surgeons performing NSS. We herewith report a case of BWT where VR planning and 3D printing were used to aid NSS. Conventional imaging is often found to be inadequate while assessing the tumour-organ-vascular anatomy. Advances like VR and 3D printing help surgeons plan better for complex surgeries like bilateral NSS. Next-generation extended reality tools will likely aid robotic-assisted precision NSS and improve patient outcomes.

[Oncological results of repeat partial nephrectomy in patients with recurrence after nephron-sparing procedures].

AIM: To carried out a comparative analysis of the risk of complications and oncological results of repeat partial nephrectomy and radical nephrectomy in patients with local recurrence after previous organ-sparing procedures. MATERIALS AND METHODS: Retrospective and prospective data of 64 patients with local recurrence of kidney cancer after nephron-sparing procedures. who underwent surgical treatment in the department of oncourology of the National Medical Research Center of Oncology named after N.N. Blokhin in the period from 2000 to 2022. A total of 37 (57.8%) patients of the main group underwent repeat partial nephrectomy, while in 27 (42.2%) patients in the control group a radical nephrectomy was done. Median follow-up was 35 (3-131; Q1-Q3: 13-57) months. Both groups were comparable in terms of demographic and clinical characteristics (p>0.05). The median time to detect relapse after previous partial nephrectomy was 24 (2-172) months. RESULTS: Complications were noted in 8 (21.6%) patients after repeat partial nephrectomy, compared to 29.6% in the control group (n=8) (p=0.563). A comparative analysis revealed a significant advantage in overall survival in patients of the main group (p=0.042). There were no significant differences between groups in cancer-specific and disease-free survival (p=0.369 and p=0.537, respectively). CONCLUSION: Repeat partial nephrectomy for local recurrence of kidney cancer leads to an increase in overall survival compared to radical nephrectomy, in the absence of significant differences in cancer-specific and relapse-free survival.

Body mass index influence on short-term perioperative results in robotic-assisted laparoscopic partial nephrectomy: a comprehensive systematic review and meta-analysis.

The objective of this meta-analysis was to evaluate the perioperative outcomes of robotic-assisted partial nephrectomy (RAPN) in obese and non-obese patients. Through March 2024, we executed an exhaustive search in internationally acclaimed databases such as PubMed, Cochrane Library, and Web of Science, limiting our scope to publications in English. We discarded review articles, protocols lacking empirical data, conference abstracts, and materials not pertinent to our research. Our analytical framework utilized the Cochran-Mantel-Haenszel method alongside a random-effects model for evaluating dichotomous variables' mean differences, expressed through odds ratios (OR) with 95% confidence intervals (CI). We established statistical significance at a P value below 0.05. The comprehensive meta-analysis incorporated data from eight cohort studies, collectively assessing 3657 patients. Findings indicated that, relative to individuals of normal weight, those in the obese category had prolonged operative durations (WMD - 25.68 95% CI - 42.07 to - 9.29; P = 0.002), increased estimated blood loss (WMD - 48.55ml, 95% CI - 78.27 to - 18.83; P = 0.001), and longer warm ischemia times (WMD - 1.11, 95% CI - 2.03 to - 0.19; P = 0.02). However, no significant disparities were observed in hospital stay duration, intraoperative and total postoperative complications, severe postoperative complications, or alterations in postoperative estimated glomerular filtration rate (eGFR). Our findings conclude that robotic-assisted partial nephrectomy (RAPN) represents a viable and safe surgical approach for obese patients. This assertion is backed by the observation that crucial metrics, including postoperative renal function alterations, surgical complication rates, and hospitalization duration, exhibit no substantial variances when juxtaposed with counterparts of normal weight.

Conversion to Radical Nephrectomy From Robotic Partial Nephrectomy Is Most Commonly Due to Anatomic and Oncologic Complexity.

PURPOSE: Partial nephrectomy is standard-of-care treatment for small renal masses. As utilization of partial nephrectomy increases and includes larger and complex tumors, the risk of conversion to radical nephrectomy likely increases. We evaluated incidence and reason for conversion to radical nephrectomy in patients scheduled for partial nephrectomy by surgeons participating in MUSIC (the Michigan Urologic Surgery Improvement Collaborative). MATERIALS AND METHODS: All patients in whom robotic partial nephrectomy was planned were stratified by completed procedure (robotic partial nephrectomy vs radical nephrectomy). Preoperative and intraoperative records were reviewed for preoperative assessment of difficulty and reason for conversion. Patient, tumor, pathologic, and practice variables were compared between cohorts. RESULTS: Of 650 patients scheduled for robotic partial nephrectomy, conversion to radical nephrectomy occurred in 27 (4.2%) patients. No conversions to open were reported. Preoperative documentation indicated a plan for possible conversion in 18 (67%) patients including partial with possible radical (n = 8), partial vs radical (n = 6), or likely radical nephrectomy (n = 4). Intraoperative documentation indicated that only 5 (19%) conversions were secondary to bleeding, with the remaining conversions due to tumor complexity and/or oncologic concerns. Patients undergoing conversion had larger (4.7 vs 2.8 cm, P < .001) and higher-complexity tumors (64% vs 6%, P < .001) with R.E.N.A.L. (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) nephrometry score ≥ 10. The converted cases had a higher rate of ≥ pT3 (27% vs 8.4%, P = .008). CONCLUSIONS: There was a low rate of conversion from robotic partial to radical nephrectomy in the MUSIC-KIDNEY (Kidney mass: Identifying and Defining Necessary Evaluation and therapY) collaborative, and an even lower risk of conversion due to uncontrolled bleeding. Targeted review of each conversion identified appropriate decision-making based on oncologic risk in most cases.

Impact of perioperative blood transfusion on prognosis after nephrectomy in patients with renal cell carcinoma: A meta-analysis and systematic review.

BACKGROUND: Perioperative blood transfusion (PBT) has been associated with worse prognosis in several malignancies. For renal cell carcinoma (RCC), the effect of PBT is still debated. OBJECTIVE: To evaluate the impact of PBT on prognosis after nephrectomy in patients with RCC. METHODS: This study is A systematic review and meta-analysis of published article data (PRISMA protocol) for literature related to PBT and RCC through extensive search of EMBASE, Medline via PubMed, Web of Science and Cochrane Library, language limited to English, with no time constraint until May 20, 2022. We pooled the results of multivariable cox regression analyses from each study, with subgroup analyses by dose and timing of transfusion. All analyses were done using Stata14. RESULTS: A total of 12 studies involving 27,683 participants were included. Our meta-analysis pooled the results of multivariable cox regression analysis in each study, showing that PBT is associated with higher overall Mortality (OM; hazard ratio [HR] = 1.34, 1.23-1.44), cancer-specific mortality (CSM; HR = 1.35, 1.20-1.51), and disease recurrence (HR = 1.54, 1.18-1.89). when only patients with nonmetastatic RCC were included, PBT was still associated with higher OM (HR = 1.29, 1.11-1.47) and disease recurrence (HR = 1.58, 1.18-1.98), but the association with CSM (HR = 1.26, 0.99-1.52) was not statistically significant. In subgroup analysis by transfusion dose, small (1-2) units of PBT were not associated with CSM (HR = 1.84, 0.95-2.73), but large (≥3) units were associated with higher CSM (HR = 2.98, 1.74-4.22) and disease recurrence (HR = 1.99, 1.31-2.67). Each additional unit of PBT resulted in a higher CSM (HR = 1.07, 1.04-1.10). In subgroup analysis by transfusion timing, intraoperative transfusion was associated with higher CSM and disease recurrence, but postoperative transfusion was not. CONCLUSIONS: PBT is associated with higher OM, CSM and disease recurrence. This adverse effect seems to be particularly significant in high-dose intraoperative transfusion. It is necessary to limit the overuse of PBT, especially high-dose intraoperative transfusion, in order to improve the prognosis of patients undergoing nephrectomy for RCC.

Open versus robotic partial nephrectomy in obese patients: a multi-institutional propensity score-matched analysis (UroCCR 43-Robese study).

INTRODUCTION: There is limited evidence on the outcomes of robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN) in obese patients (BMI ≥ 30 kg/m2). In this study, we aimed to compare perioperative and oncological outcomes of RPN and OPN. METHODS: We relied on data from patients who underwent PN from 2009 to 2017 at 16 departments of urology participating in the UroCCR network, which were collected prospectively. In an effort to adjust for potential confounders, a propensity-score matching was performed. Perioperative outcomes were compared between OPN and RPN patients. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: Overall, 1277 obese patients (932 robotic and 345 open were included. After propensity score matching, 166 OPN and 166 RPN individuals were considered for the study purposes; no statistically significant difference among baseline demographic or tumor-specific characteristics was present. A higher overall complication rate and major complications rate were recorded in the OPN group (37 vs. 25%, p = 0.01 and 21 vs. 10%, p = 0.007; respectively). The length of stay was also significantly longer in the OPN group, before and after propensity-score matching (p < 0.001). There were no significant differences in Warm ischemia time (p = 0.66), absolute change in eGFR (p = 0.45) and positive surgical margins (p = 0.12). At a median postoperative follow-up period of 24 (8-40) months, DFS and OS were similar in the two groups (all p > 0.05). CONCLUSIONS: In this study, RPN was associated with better perioperative outcomes (improvement of major complications rate and LOS) than OPN. The oncological outcomes were found to be similar between the two approaches.