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Article of the Week: Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Craig Rogers, discussing his paper.

If you only have time to read one article this week, it should be this one.

Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

 

Newaj Abdullah*, Haider Rahbar*, Ravi Barod*, Deepansh Dalela*, Jeff LarsonMichael Johnson, Alon Mass§, Homayoun Zargar, Mohamad Allaf, Sam BhayaniMichael Stifelman§, Jihad Kaouk¶ and Craig Rogers*

 

*Vattikutti Urology Institute, Henry Ford Health System, Detroit, MI, Division of Urology, Washington University in St. Louis, St. Louis, MO, James Buchanan Brady Urological Institute, John Hopkins University, Baltimore, MD, §Department of Urology, New York University, New York, NY, and Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

 

Objective

To evaluate the outcomes of robot-assisted partial nephrectomy RAPN after major prior abdominal surgery (PAS) using a large multicentre database.

Patients and methods

We identified 1 686 RAPN from five academic centres between 2006 and 2014. In all, 216 patients had previously undergone major PAS, defined as having an open upper midline/ipsilateral incision. Perioperative outcomes were compared with those 1 470 patients who had had no major PAS. The chi-squared test and Mann–Whitney U-test were used for categorical and continuous variables, respectively.

AugAOTW4FI

Results

There was no statistically significant difference in Charlson comorbidity index, tumour size, R.E.N.A.L. nephrometry score or preoperative estimated glomerular filtration rate (eGFR) between the groups. Age and body mass index were higher in patients with PAS. The PAS group had a higher estimated blood loss (EBL) but this did not lead to a higher transfusion rate. A retroperitoneal approach was used more often in patients with major PAS (11.2 vs 5.4%), although this group did not have a higher percentage of posterior tumours (38.8 vs 43.3%, P = 0.286). Operative time, warm ischaemia time, length of stay, positive surgical margin, percentage change in eGFR, and perioperative complications were not significantly different between the groups.

Conclusions

RAPN in patients with major PAS is safe and feasible, with increased EBL but no increased rate of transfusion. Patients with major PAS had almost twice the likelihood of having a retroperitoneal approach.

Editorial: Robot-assisted partial nephrectomy: excellent outcomes can persist despite previous abdominal surgery

Robot-assisted surgery is increasing and patient selection is important to ensure mitigation of risk, patient safety and allow for the surgeon’s training curve. This is especially pertinent for robot-assisted partial nephrectomy (RAPN), as increasingly complex tumours and increasingly complex patients are considered potentially suitable. One factor that contributes to patient complexity is the presence of intra-abdominal adhesions, which can be predicted by previous abdominal surgery. This month’s article by Abdullah et al. [1] ‘Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery’ eloquently describes their outcomes in patients who underwent RAPN with a history of previous open abdominal surgery.

The study retrospectively analysed 1 686 patients who had undergone RAPN from a prospective database from five large American academic institutions. A sub-group of 216 patients (13%) had undergone major prior abdominal surgery (PAS); this was defined as those marked by upper midline or ipsilateral incisions. The authors chose such incisions due to the increased potential for adhesions within the expected surgical field for RAPN, which could interfere with performance [2]. The list of prior surgeries is wide ranging such as laparotomy, open cholecystectomy, open appendicectomy and open ipsilateral PN; 12% (25 patients) had had multiple previous procedures.

The study found that there was no statistical difference between the two groups in the areas of Charlson comorbidities index, tumour size, R.E.N.A.L. nephrometry score [consists of (R)adius (tumour size as maximal diameter), (E)xophytic/endophytic properties of the tumour, (N)earness of tumour deepest portion to the collecting system or sinus, (A)nterior (a)/posterior (p) descriptor and the (L)ocation relative to the polar line], and preoperative estimated GFR. They also found no difference between intraoperative and postoperative complications (<4% Clavien ≥3 in PAS group), positive surgical margins and change in renal function.

Their initial concern that previous surgery increases robotic operative time was ill founded, as there was no statistical difference in median (interquartile range) operative times: PAS 172 (132–224) vs169 (139–208) min. However, they did find statistical difference in estimated blood loss, which was higher in the PAS group (150 vs 100 mL; P = 0.039); but this did not translate to a difference in transfusion rates.

They also found the PAS patients were older (median 63 vs 60 years) and had a higher median body mass index (30.3 vs 29 kg/m2). This is an important finding in the context of offering robotic minimally invasive surgery in an increasingly obese and ageing surgical population.

Achieving safe access is a crucial step in all laparoscopic or robot-assisted surgery and is potentially complicated by the presence of adhesions. It was of particular interest to read of the access techniques used: Hasson vs Veress needle vs retroperitoneal approach. The latter was used more in the PAS group (11.2% vs 5.4%), despite a lower percentage of posterior tumours (38.8% vs 43.3%). This suggests surgical preference for choosing a retroperitoneal approach was related to avoidance of potential adhesions rather than tumour location.

Conceptually the Hassan technique, with access achieved by direct vision, could offer safety benefits in the presence of potential adhesions; however, access via Veress needle insufflation occurred in most of their cases. The authors describe the use of the Hassan technique in instances of failure of Veress access but the incidence that this occurred is not provided. They estimated that 24 cases were converted to open due to access-related issues.

Further interrogation of the 180 open PNs performed during the study period could provide a valuable comparative group and understand why they were not deemed suitable for a robot-assisted approach.

The study can be commended for its large patient database, multicentre design, and breadth of outcomes assessed. It supports the findings of Zargar et al. [3] showing comparable perioperative complications and open conversions of RAPN in patients with and without a history of PAS in their similar sized, but single-centre study. This is also in agreement with assessments of other robotic procedures supporting the relative safety of robotic surgery in patients with a history of PAS.

One of the limitations of this study is the lack of discussion on the decision-making process for choice of access technique. Individual surgeons and/or the recommendations of multi-disciplinary teams will favour the technique with the perceived best outcome and may select out more favourable cases to each arm. Abdullah et al. [1] results may be an indication of appropriate technique selection rather than safety of the robot or individual access techniques.

This study provides robotic surgeons with increasing confidence to offer RAPN and its potential advantages of reduced blood loss, pain and recovery time to patients despite the presence of potential adhesions from PAS. Individual case selection remains imperative to maintain optimal surgical outcomes. Complex cases may be safely tackled in high-volume established RAPN programmes; but they may not be suitable for surgeons earlier in their experience. Robotic surgeons should be well trained and confident in managing the potential complications of bowel injury in these challenging cases.

Sophie Rintoul-Hoad, Rick Catterwell and Ben Challacombe
Urology Centre, Guys and St Thomas Hospitals NHS Trust, Great Maze Pond, London, UK

 

Read the full article

 

References

 

1 Abdullah N, Rahbar H, Barod R et al. Multicentre outcomes of robot- assisted partial nephrectomy after major open abdominal surgery. BJU Int 2016; 118: 298301

 

2 Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical signicance. Recent advances in prevention and management. Dig Surg 2001; 18: 26073

 

 

Video: Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

Multicentre outcomes of robot-assisted partial nephrectomy after major open abdominal surgery

Newaj Abdullah*, Haider Rahbar*, Ravi Barod*, Deepansh Dalela*, Jeff LarsonMichael Johnson, Alon Mass§, Homayoun Zargar, Mohamad Allaf, Sam BhayaniMichael Stifelman§, Jihad Kaouk¶ and Craig Rogers*

 

*Vattikutti Urology Institute, Henry Ford Health System, Detroit, MI, Division of Urology, Washington University in St. Louis, St. Louis, MO, James Buchanan Brady Urological Institute, John Hopkins University, Baltimore, MD, §Department of Urology, New York University, New York, NY, and Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA

 

Objective

To evaluate the outcomes of robot-assisted partial nephrectomy RAPN after major prior abdominal surgery (PAS) using a large multicentre database.

Patients and methods

We identified 1 686 RAPN from five academic centres between 2006 and 2014. In all, 216 patients had previously undergone major PAS, defined as having an open upper midline/ipsilateral incision. Perioperative outcomes were compared with those 1 470 patients who had had no major PAS. The chi-squared test and Mann–Whitney U-test were used for categorical and continuous variables, respectively.

AugAOTW4FI

Results

There was no statistically significant difference in Charlson comorbidity index, tumour size, R.E.N.A.L. nephrometry score or preoperative estimated glomerular filtration rate (eGFR) between the groups. Age and body mass index were higher in patients with PAS. The PAS group had a higher estimated blood loss (EBL) but this did not lead to a higher transfusion rate. A retroperitoneal approach was used more often in patients with major PAS (11.2 vs 5.4%), although this group did not have a higher percentage of posterior tumours (38.8 vs 43.3%, P = 0.286). Operative time, warm ischaemia time, length of stay, positive surgical margin, percentage change in eGFR, and perioperative complications were not significantly different between the groups.

Conclusions

RAPN in patients with major PAS is safe and feasible, with increased EBL but no increased rate of transfusion. Patients with major PAS had almost twice the likelihood of having a retroperitoneal approach.

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