Evaluation of oncological outcomes of robotic partial nephrectomy according to the type of hilar control approach (On-clamp vs Off-clamp), a multicentric study of the French network of research on kidney cancer-UROCCR 58-NCT03293563.

PURPOSE: To compare off-clamp vs on-clamp robotic partial nephrectomy (RPN) for renal cell carcinoma (RCC) in terms of oncological outcomes, and to assess the impact of surgical experience (SE). METHODS: We extracted data of a contemporary cohort of 1359 patients from the prospectively maintained database of the French national network of research on kidney cancer (UROCCR). The primary objective was to assess the positive surgical margin (PSM) rate. We also evaluated the oncological outcomes regardless of the surgical experience (SE) by dividing patients into three groups of SE as a secondary endpoints. SE was defined by the caseload of RPN per surgeon per year. For the continuous variables, we used Mann-Whitney and Student tests. We assessed survival analysis according to hilar control approach by Kaplan-Meier curves with log rank tests. A logistic regression multivariate analysis was used to evaluate the independent factors of PSM. RESULTS: Outcomes of 224 off-clamp RPN for RCC were compared to 1135 on-clamp RPN. PSM rate was not statistically different, with 5.6% in the off-clamp group, and 11% in the on-clamp group (p = 0.1). When assessing survival analysis for overall survival (OS), local recurrence-free survival (LR), and metastasis-free survival (MFS) according to hilar clamping approach, there were no statistically significant differences between the two groups with p value log rank = 0.2, 0.8, 0.1, respectively. In multivariate analysis assessing SE, hilar control approach, hospital volume (HV), RENAL score, gender, Age, ECOG, EBL, BMI, and indication of NSS, age at surgery was associated with PSM (odds ratio [OR] 1.03 (95% CI 1.00-1.04), 0.02), whereas SE, HV, and type of hilar control approach were not predictive factors of PSM. CONCLUSION: Hilar control approach seems to have no impact on PSM of RPN for RCC. Our findings were consistent with randomized trials.

[Medico-economic evaluation of the impact of measures to adapt to the switch to surgery robot-assisted in urology]. / Évaluation médico-economique de l'impact de mesures d'adaptation au virage de la chirurgie robot-assistée en urologie.

INTRODUCTION: The development of robot-assisted urological surgery is held back by the lack of robust medico-economic analyses and their heterogeneity. We conducted a medico-economic study to evaluate the implementation of measures to optimize the transition to robotic surgery. METHOD: We carried out a single-center, controlled study from the point of view of the public healthcare establishment for 4 years. Economic data collection was based on a micro-costing method and revenues from stay-related groups. Clinical data corresponded to mean lengths of stay, operating duration, complications and stays in intensive care. The measures to optimize the transition to robotic, implemented mid-study period, enabled before/after comparison. RESULTS: Altogether, 668 patients undergoing robotic surgery were included. Robotic activity increased significantly from periods 1 to 2 to 256% (P=<0.001) as did the overall proportion of robotic by 45% to 85% (P=<0.001). The mean lengths of stay fell significantly, 6.8 d vs. 5.1 d (P<0.001). Costs and revenues increased significantly, resulting in a persistent deficit for the activity €226K vs. €382K (P=<0.001). With increased volume of activity, the deficit per operation and the cost per minute of robotic operating room fell significantly, €3,284 vs. €1,474/procedure (P=<0.001) and €27 vs €24/min (P=<0.029), tending towards a break-even point (=zero deficit) at 430 operations per year. CONCLUSIONS: Robotic-assisted surgery can be significantly optimized by implementing measures for the robotic turn to reach a break-even point at 430 operations per year. A better multidisciplinary case mix could lower the break-even volume of activity in short term. LEVEL OF EVIDENCE: 3.