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Article of the week: Suture techniques during laparoscopic and robot‐assisted partial nephrectomy

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 a video produced by the authors. Please use the tools at the bottom of the post if you would like to make a comment. 

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

Suture techniques during laparoscopic and robot‐assisted partial nephrectomy: a systematic review and quantitative synthesis of peri‐operative outcomes

Riccardo Bertolo*, Riccardo Campi, Tobias Klatte, Maximilian C. Kriegmair§Maria Carmen Mir, Idir Ouzaid**, Maciej Salagierski††, Sam Bhayani‡‡, Inderbir Gill§§¶¶Jihad Kaouk* and Umberto Capitanio‡‡§§***††† On behalf of the Young Academic Urologists (YAU) Kidney Cancer working group of the European Urological Association (EAU)

 

*Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, USA, Department of Urology, University of Florence, Florence, Italy, Department of Urology, Royal Bournemouth and Christchurch Hospitals, Bournemouth, UK, §Department of Urology, University Medical Centre Mannheim, Mannheim, Germany, Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain, **Department of Urology, Bichat Hospital, APHP, Paris Diderot University, Paris, France, ††Urology Department, Faculty of Medicine and Health Sciences, University of Zielona ra, Zielona Góra, Poland, ‡‡Division of Urology, Washington University School of Medicine, St Louis, MO, §§Keck School of Medicine, USC Institute of Urology, ¶¶Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA, ***Department of Urology, San Raffaele ScientifiInstitute, and †††Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy

 

Abstract

Objective

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri‐operative outcomes after minimally invasive partial nephrectomy (MIPN).

Materials and Methods

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot‐assisted partial nephrectomy and comparative studies focused on peri‐operative outcomes were included in qualitative and quantitative analyses, respectively.

Fig. 4. Integrated overview of evidence‐based technical principles for renal reconstruction during minimally invasive partial nephrectomy and suggested standardized reporting of key renorrhaphy features in clinical studies on this topic.

Results

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon’s experience, robot‐assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non‐barbed suture. The single‐layer suture technique was associated with shorter operating and ischaemia time than the double‐layer technique. No comparisons were possible concerning renal functional outcomes because of non‐homogeneous data reporting.

Conclusions

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double‐layer suture.

 

 

 

Video: Suture techniques during laparoscopic and robot‐assisted partial nephrectomy

Suture techniques during laparoscopic and robot‐assisted partial nephrectomy: a systematic review and quantitative synthesis of peri‐operative outcomes

by Riccardo Bertolo (@RicBertolo)

Abstract

Objective

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri‐operative outcomes after minimally invasive partial nephrectomy (MIPN).

Materials and Methods

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot‐assisted partial nephrectomy and comparative studies focused on peri‐operative outcomes were included in qualitative and quantitative analyses, respectively.

Results

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon’s experience, robot‐assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non‐barbed suture. The single‐layer suture technique was associated with shorter operating and ischaemia time than the double‐layer technique. No comparisons were possible concerning renal functional outcomes because of non‐homogeneous data reporting.

Conclusions

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double‐layer suture.

Article of the month: Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study

Every month, the Editor-in-Chief selects an Article of the Month 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 editorial written by a prominent member of the urological community and the authors have also kindly produced a video describing their work. These are 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. 

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

Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study

Cedric Lebacle* , Karim Bensalah, Jean-Christophe Bernhard§, Laurence AlbigesBrigitte Laguerre**, Marine Gross-Goupil††, Herve Baumert‡‡, Herve Lang§§, Thibault Tricard§§, Brigitte Duclos¶¶, Armelle Arnoux***, Celine Piedvache***, Jean-Jacques Patard††† and Bernard Escudier

 

*Department of Urology, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, APHP, University Paris-Saclay, Le Kremlin-Bicêtre, Department of Urology, Pontchaillou University Hospital, Rennes, Department of Urology, Bordeaux University Hospital, Pellegrin Hospital, §French Research Network on Kidney Cancer UroCCR, Bordeaux, Department of Medicine, Gustave Roussy, University Paris-Saclay, Villejuif, **Department of Oncology, Eugene Marquis Centre, Rennes, ††Department of Medical Oncology, Bordeaux University Hospital, Saint-André Hospital, Bordeaux, ‡‡Department of Urology, Saint-Joseph Hospital, Paris, §§Department of Urology, Nouvel Hôpital Civil, ¶¶Department of Oncology, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, ***Paris-Sud Clinical Research Unit, Department of Statistics, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre and †††Department of Urology, Mont de Marsan Hospital, Mont de Marsan, France

 

Abstract

Objective

To evaluate the ability of neoadjuvant axitinib to reduce the size of T2 renal cell carcinoma (RCC) for shifting from a radical nephrectomy (RN) to a partial nephrectomy (PN) indication, offering preservation of renal function.

Patients and Methods

Patients with cT2aN0NxM0 clear‐cell RCC, considered not suitable for PN, were enrolled in a prospective, multicentre, phase II trial (AXIPAN). Axitinib 5 mg, and up to 7–10 mg, was administered twice daily, for 2–6 months before surgery, depending on the radiological response. The primary outcome was the number of patients receiving PN for a tumour <7 cm in size after neoadjuvant axitinib.

Results

Eighteen patients were enrolled. The median (range) tumour size and RENAL nephrometry score were 76.5  (70–98) mm and 11 (7–11), respectively. After axitinib neoadjuvant treatment, 16 tumours decreased in diameter, with a median size reduction of 17% (64.0 vs 76.5 mm; P < 0.001). The primary outcome was considered achieved in 12 patients who underwent PN for tumours <7 cm. Sixteen patients underwent PN. Axitinib was tolerated in the present study, as has been previously shown in the metastatic setting. Five patients had grade 3 adverse events. Five patients experienced Clavien III–V post‐surgery complications. At 2‐year follow‐up, six patients had metastatic progression, and two had a recurrence.

Conclusion

Neoadjuvant axitinib in cT2 ccRCC is feasible and, even with a modest decrease in size, allowed a tumour shrinkage <7 cm in 12 cases; however, PN procedures remained complex, requiring surgical expertise with possible morbidity.

Editorial: Expanding the feasibility of nephron‐sparing surgery: time for a paradigm shift?

With the rapid implementation of ‘targeted’ therapies, kidney cancer has entered a new era where old paradigms are being challenged, and new ones can be explored. The idea of delivering ‘neoadjuvant’ systemic therapy to alter the surgical treatment of advanced RCC was suggested in this same journal ~10 years ago as a proof‐of‐concept study [1]. Since then, a plethora of small case series has investigated the safety and feasibility of different targeted agents in the preoperative setting to facilitate surgical resection of locally advanced disease, mostly with a ‘cytoreductive’ (rather than ‘curative’) intent.

In this issue of the BJU Int, Lebacle et al. [2] evaluated the role of neoadjuvant axitinib, an oral tyrosine kinase inhibitor currently recommended as a second‐line option for metastatic clear cell RCC, to downstage cT2 kidney cancer and allow a partial nephrectomy (PN). In this multicentre prospective study, 18 patients with RCC (median tumour size 7.6 cm and R.E.N.A.L. [Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location] score 11) were enrolled. A median tumour size reduction of 17% was obtained, and the primary outcome (‘clinical downstaging’ to cT1 to allow PN) was achieved in 12 patients (67%). Overall, 16 patients underwent PN, as this was successfully done also in four of six (67%) patients who were not ‘down‐staged’ by the drug. Notably, about half of the PNs were performed with a robotic approach. Whilst axitinib was well tolerated, five patients experienced a high‐grade complication after surgery, including one death. Interestingly, final pathology showed upstaging to pT3a disease in seven patients, and two positive margins. Moreover, about a third of patients had metastatic progression and two had recurrence at 2 years. Thus, while the authors noted axitinib to be effective in reducing tumour size and achieving a clinical downstaging in most patients, the significant presence of pT3a disease calls into question the overall efficacy (to truly pathologically downstage) or desirability (most of the tumours that were not downstaged still successfully underwent PN) of the study’s main stated aim.

The rapid adoption of robotic surgery and the increasing experience with PN techniques translated into expanding indications for minimally invasive nephron‐sparing surgery (NSS), to include also T1b and T2 renal masses [3], and the field is primed for a possible paradigm shift. Whether or not a PN is doable, regardless of the technique, remains in the hands of the surgeon, who makes that decision based on previous personal experience. This is also the case for the present study, where the primary outcome was simply represented by the number of patients who could get a PN (instead of a radical nephrectomy). As such, is such a subjective endpoint (feasibility of PN) clinically meaningful? While disagreement may occur over the risk of PN in complex and elective cases, the desirability of nephron preservation in imperative and most elective circumstances is supported by evidence that largely suggests that PN translates into better renal function. In addition, recent findings suggest that estimated GFR preservation might translate into better cancer‐specific survival [4]. Certainly, this type of endpoint (whether a PN is feasible) is prone to intrinsic bias and limitations.

Only a limited number of studies have specifically explored the role of neoadjuvant therapy to enable NSS with variable results [5] (Table 1) [2, 6, 7, 8, 9]. Overall, these studies suggest that even a modest tumour size reduction can facilitate kidney preservation in a significant number of cases. Amongst these studies, only one had assessed axitinib in this specific setting [9]. Differences in outcomes between that trial and the present one by Lebacle et al. [2] could be explained by differences in study populations and/or drug regimens. A more recent study by Karam et al. [10], showed that inter‐observer agreement regarding the feasibility of a PN is quite variable, which is not surprising. For this reason, those authors advocated the need for a ‘resectability score’.

In conclusion, utility of neoadjuvant therapy to modify tumour size and facilitate NSS is an active and exciting area of clinical investigation, fuelled by the rapidly changing landscape of systemic therapies for RCC. It is too early to call for a paradigm shift, but a few ongoing studies might provide some meaningful answers soon. Amongst these, the PADRES (Prior Axitinib as a Determinant of Outcome of REnal Surgery) is an ongoing North American multicentre phase II study of axitinib with the aim of recruiting 50 patients [5]. While waiting for more robust evidence, the use of neoadjuvant therapy to facilitate NSS should still be deemed as investigational.

References

  1. Shuch, BRiggs, SBLaRochelle, JC et al. Neoadjuvant targeted therapy and advanced kidney cancer: observations and implications for a new treatment paradigm. BJU Int 2008102692– 6
  2. Lebacle, CBensalah, KBernhard, JC et al. Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study. BJU Int 2019123804– 10
  3. Bertolo, RAutorino, RSimone, G et al. Outcomes of robot‐assisted partial nephrectomy for clinical T2 renal tumors: a multicenter analysis (ROSULA Collaborative Group). Eur Urol 201874:226– 32
  4. Antonelli, AMinervini, ASandri, M et al. Below safety limits, every unit of glomerular filtration rate counts: assessing the relationship between renal function and cancer‐specific mortality in renal cell carcinoma. Eur Urol 201874661– 7
  5. Bindayi, AHamilton, ZAMcDonald, ML et al. Neoadjuvant therapy for localized and locally advanced renal cell carcinoma. Urol Oncol 20183631– 7
  6. Silberstein, JLMillard, FMehrazin, R et al. Feasibility and efficacy of neoadjuvant sunitinib before nephron‐sparing surgery. BJU Int 20101061270– 6
  7. Rini, BIPlimack, ERTakagi, T et al. A phase II study of pazopanib in patients with localized renal cell carcinoma to optimize preservation of renal parenchyma. J Urol 2015194297– 303
  8. Lane, BRDerweesh, IHKim, HL et al. Presurgical sunitinib reduces tumor size and may facilitate partial nephrectomy in patients with renal cell carcinoma. Urol Oncol 201533112.e15–21.
  9. Karam, JADevine, CEUrbauer, DL et al. Phase 2 trial of neoadjuvant axitinib in patients with locally advanced nonmetastatic clear cell renal cell carcinoma. Eur Urol 201466874– 80
  10. Karam, JADevine, CEFellman, BM et al. Variability of inter‐observer agreement on feasibility of partial nephrectomy before and after neoadjuvant axitinib for locally advanced renal cell carcinoma (RCC): independent analysis from a phase II trial. BJU Int 2016117629– 35

 

Video: Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study

Evaluation of axitinib to downstage cT2a renal tumours and allow partial nephrectomy: a phase II study

Abstract

Objective

To evaluate the ability of neoadjuvant axitinib to reduce the size of T2 renal cell carcinoma (RCC) for shifting from a radical nephrectomy (RN) to a partial nephrectomy (PN) indication, offering preservation of renal function.

Patients and Methods

Patients with cT2aN0NxM0 clear‐cell RCC, considered not suitable for PN, were enrolled in a prospective, multicentre, phase II trial (AXIPAN). Axitinib 5 mg, and up to 7–10 mg, was administered twice daily, for 2–6 months before surgery, depending on the radiological response. The primary outcome was the number of patients receiving PN for a tumour <7 cm in size after neoadjuvant axitinib.

Results

Eighteen patients were enrolled. The median (range) tumour size and RENAL nephrometry score were 76.5  (70–98) mm and 11 (7–11), respectively. After axitinib neoadjuvant treatment, 16 tumours decreased in diameter, with a median size reduction of 17% (64.0 vs 76.5 mm; P < 0.001). The primary outcome was considered achieved in 12 patients who underwent PN for tumours <7 cm. Sixteen patients underwent PN. Axitinib was tolerated in the present study, as has been previously shown in the metastatic setting. Five patients had grade 3 adverse events. Five patients experienced Clavien III–V post‐surgery complications. At 2‐year follow‐up, six patients had metastatic progression, and two had a recurrence.

Conclusion

Neoadjuvant axitinib in cT2 ccRCC is feasible and, even with a modest decrease in size, allowed a tumour shrinkage <7 cm in 12 cases; however, PN procedures remained complex, requiring surgical expertise with possible morbidity.

Article of the Week: Impact of warm ischaemia time on postoperative renal function after partial nephrectomy for clinical T1 renal cell carcinoma

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.

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

Impact of warm ischaemia time on postoperative renal function after partial nephrectomy for clinical T1 renal cell carcinoma: a propensity score-matched study

Hakmin Lee*, Byung D. Song*, Seok-Soo Byun*, Sang E. Lee* and Sung K. Hong*
*Department of Urology, Seoul National University Bundang Hospital, Seongnam, and Department of Urology, Seoul National University College of Medicine, Seoul, Korea

 

Objectives

To analyse the effect of prolonged warm ischaemia time (WIT) on long-term renal function after partial nephrectomy (PN), as controversy still exists as to whether prolonged WIT adversely affects the incidence of chronic kidney disease (CKD) after PN.

Patients and Methods

We reviewed data from 1816 patients who underwent PN for a clinical T1 renal tumour. The propensity scores for prolonged WIT were calculated with the shorter WIT group (<30 min) matched to the longer WIT group (≥30 min) in a 2:1 ratio. Multivariate analysis was used to determine independent predictors for occurrence of postoperative CKD [defined as an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2] and major renal function deterioration (MRFD; defined as an eGFR decrease of ≥25% postoperatively).

Results

After propensity score matching, there was no significant difference in CKD-free survival between the two WIT groups (P = 0.787). Furthermore, longer WIT did not show any significant associations with postoperative CKD-free survival [hazard ratio (HR) 1.002, 95% confidence interval (CI) 0.989–1.015; P = 0.765) and MRFD-free survival (HR 1.014, 95% CI 1.000–1.028; P = 0.055). From further subgroup analyses using more specific WIT thresholds (≤20, 21–30, 31–40, 41–50, ≥50 min) and status of preoperative CKD, no significant differences were noted in CKD and MRFD-free survival amongst the subgroups (all P > 0.05).

Conclusions

Prolonged WIT was not associated with increased incidence of CKD or MRFD after PN.

Editorial: Impact of warm ischaemia time during partial nephrectomy on renal function – is it really a matter of time?

In the latest edition of the BJUI, Lee et al. [1] have revisited the question of defining the ideal limit of warm ischaemia time (WIT) and its impact on postoperative renal function in patients undergoing partial nephrectomy (PN).

Partial nephrectomy has replaced radical nephrectomy as the preferred treatment for T1 renal masses. This publication challenges the theory that ischaemic nephropathy is inevitable if the renal vessels are clamped beyond 30 min, leading to a long-term decline in renal function.

The authors in this series are to be commended for analysing a prospectively collected database on 1 816 patients in two institutions who underwent PN for clinical T1 renal tumours. Their primary endpoint was to investigate the impact of prolonged WIT on long-term renal function focusing on two clinical endpoints; chronic kidney disease, as estimated by an estimated GFR of <60 mL/min/1.73 m2, and major renal function deterioration defined as an increase in creatinine of >25% of the preoperative value.

Warm ischaemia time using a threshold of 30 min created two comparative groups. Patients were followed for up to 40 months after surgery. In addition to this, patients were further sub-stratified into five subgroups, critiquing the effect of WIT up to 50 min. A key feature of this paper [1] is the use of propensity score matching to adjust for any potential preoperative confounders affecting postoperative renal function, a technique also allowing matching of the two groups.

The authors correctly emphasise the direct relationship between tumour size and duration of WIT, with larger tumours requiring excision of more renal parenchyma and adding to ‘on-clamp’ time. Tumour size and renal function are vital determinants of suitability for PN [2]. This publication [1] clearly demonstrates that although large tumour size equated with prolonged clamp time, this was not the sole determinant of impaired long-term renal function.

The importance of other independent variables such as preoperative renal function, patient age and preserved renal parenchyma have been highlighted here as potentially playing a greater role than was previously appreciated.

The second and possibly more remarkable finding from this paper is that ischaemic time was not an independent predictor of ultimate renal function after PN. This contrasts with most other reports to date. Although not recommending using a WIT of up to 50 min, the results here suggest this may not be relevant to future renal function. It appears that long-term renal function after PN is primarily determined by the quantity and quality of renal parenchyma preserved, although the type and duration of ischaemia remain the most important modifiable factors, and warrant further evaluation [3].

When discussing this topic, it is interesting to refer to the initial bench work on this issue. The current approach to WIT is extrapolated from data derived from the histological changes occurring in nephrons during operative stone cases. From the data presented in this and other studies, it seems more relevant than ever to conduct clinical trials to assess this appropriately. Traditionally the time threshold for WIT is taken as 30 min, an arbitrarily placed time-point based on the above laboratory data. Beyond this value in the setting of room temperature renal ischaemia creates an array of injury centred on cellular adaptations beginning ~20 min after clamping and persisting beyond 60 min. This indicates that the traditional 30-min limit of WIT is a somewhat subjective time point and was not based on clinical outcomes.

Previous evidence suggests a 5% increase in risk for acute renal failure for every additional minute of WIT [4]. It is hard to ignore such data in exchange for this a contemporary study when so much is at stake for patient longevity. Advocators of zero-ischaemia PN have shown that those who benefit most from a zero-ischaemia technique are those with the poorest baseline renal function [5]. Most of these studies have shown that the renal functional outcomes are either equivalent or superior in zero-ischaemia cases involving small renal tumours [6].

On balance, the authors are to be credited with tackling such a controversial matter and highlighting the lack of good quality laboratory data. Clearly, factors other than WIT contribute to postoperative renal function but for now we must conclude that every minute ‘on-clamp’ does count.

Eva M. Bolton and Thomas H. Lynch
St. Jamess Hospital, Dublin, Ireland

References

1 Lee H, Song BD, Byun SS, Lee SE, Hong SK. Impact of warm ischaemia time on postoperative renal function after partial nephrectomy for clinical T1 renal cell carcinoma: a propensity score-matched study. BJU Int 2018; 121: 4652

 

2 Volpe A, Blute ML, Ficarra V et al. Renal ischemia and function after partial nephrectomy: a collaborative review of the literature. Eur Urol 2015; 68: 6174

 

3 Lane BR, Russo P, Uzzo RG et al. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodiable factors in determining ultimate renal function. J Urol 2011; 185: 4217

 

4 Thompson RH, Lane BR, Lohse CM et al. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol 2010;58: 3405

 

 
6 Salami SS, George AK, Rais-Bahrami S, Okhunov Z, Waingankar NKavoussi LR. Off-clamp laparoscopic partial nephrectomy for hilar tumors: oncologic and renal functional outcomes. J Endourol 2014; 28: 1915

 

Article of the Week: Early surgical outcomes and oncological results of RAPN

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.

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

Early surgical outcomes and oncological results of robot-assisted partial nephrectomy: a multicentre study

 

Rajan Veeratterapillay*, Sanjai K. Addla, Clare Jelley, John Bailie*, David Rix*,Steve Bromage, Neil Oakley, Robin Weston§ and Naeem A. Soomro*

 

*Department of Urology, Freeman Hospital, Newcastle Upon Tyne, Department of Urology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, Department of Urology, Stepping Hill Hospital, Stockport, and §Department of Urology, Royal Liverpool University Hospital, Liverpool, UK

 

Abstract

Objective

To describe a multicentre experience of robot-assisted partial nephrectomy (RAPN) in northern England, with focus on early surgical outcomes and oncological results.

Patients and Methods

All consecutive patients undergoing RAPN at four tertiary referral centres in northern England in the period 2012–2015 were included for analysis. RAPN was performed via a transperitoneal approach using a standardized technique. Prospective data collection was performed to capture preoperative characteristics (including R.E.N.A.L. nephrometry score), and peri-operative and postoperative data, including renal function. Correlations between warm ischaemia time (WIT), positive surgical margin (PSM) rate, complication rates, R.E.N.A.L. nephrometry scores and learning curve were assessed using univariate and multivariate analyses.

Results

A total of 250 patients (mean age 58.1 ± 13 years, mean ± sd body mass index 27.3 ± 7 kg/m2) were included, with a median (range) follow-up of 12 (3–36) months. The mean ± sd tumour size was 30.6 ± 10 mm, mean R.E.N.A.L. nephrometry score was 6.1 ± 2 and 55% of tumours were left-sided. Mean ± sd operating console time was 141 ± 38 min, WIT 16.7 ± 8 min and estimated blood loss 205 ± 145 mL. There were five conversions (2%) to open/radical nephrectomy. The overall complication rate was 16.4% (Clavien I, 1.6%; Clavien II, 8.8%; Clavien III, 6%; Clavien IV/V; 0%). Pathologically, 82.4% of tumours were malignant and the overall PSM rate was 7.3%. The mean ± sd preoperative and immediate postoperative estimated glomerular filtration rates were 92.8 ± 27 and 80.8 ± 27 mL/min/1.73 m2, respectively (P = 0.001). In all, 66% of patients remained in the same chronic kidney disease category postoperatively, and none of the patients required dialysis during the study period. ‘Trifecta’ (defined as WIT < 25 min, negative surgical margin status and no peri-operative complications) was achieved in 68.4% of patients overall, but improved with surgeon experience. PSM status and long WIT were significantly associated with early learning curve.

Conclusion

This is the largest multicentre RAPN study in the UK. Initial results show that RAPN is safe and can be performed with minimal morbidity. Early oncological outcomes and renal function preservation data are encouraging.

Editorial: From Novick to the NHS – the evolution of minimally-invasive NSS

The publication in this issue of the BJUI by Veeratterapillay et al. [1] of a UK multicentre study in a community setting marks a watershed in the availability and quality of minimally invasive nephron-sparing surgery (NSS) for renal cancer. Such a turning point was predicted almost 17 years ago by Novick [2] when he wrote, ‘minimally invasive modalities of tumour resection or destruction should be reserved for highly select patients and awaits improvements in technology, standardization of technique and long-term outcomes data before they may be completely integrated options’. It appears now that robot-assisted surgery provides such a platform. The present study [1] describes the outcomes of patients treated with robot-assisted partial nephrectomy (RAPN) at four centres in Northern England, and shows very good outcomes within their first 250 cases.

The benefits of NSS have been well described. Indeed, excellent outcomes for PN were described over 20 years ago in carefully selected cases, with benefits including reduced incidence of renal insufficiency compared to radical nephrectomy, which until that time had been viewed as the ‘gold-standard’ for patients with RCC [3]. However, the popularity of PN for small renal masses appeared to decline with the advent of laparoscopy. It became apparent that a minimally invasive approach to radical nephrectomy had the advantage of improved recovery, reduced blood loss with equal cancer control to open nephrectomy [4]. Notwithstanding absolute and relative indications for PN, given the choice between an open PN and a laparoscopic radical nephrectomy, the balance for patients with an elective indication for PN was tipped in favour of a minimally invasive yet radical approach [5]. Techniques for PN were in their infancy, and even in the leading high-volume centres outcomes, including warm ischaemia time (WIT) and positive surgical margin (PSM) rate, failed to match those of open surgery [6].

Fast forward to 2017 with the increasing use of robot-assisted urological surgery carrying the advantages of three-dimensional vision, wristed movement and integrated real-time intraoperative imaging, especially beneficial for procedures such as PN where quick and accurate suturing are essential for a successful outcome. Veeratterapillay et al. [1] present a series of 250 patients from centres in the UK, in which each performs <50 RAPN procedures/year, yet the authors present favourable outcomes overall, with a PSM rate of 7.3%, major complications in 6% and trifecta in 68.4%. An impressive learning curve is seen with improving outcomes over the series, such that in the final 50 cases a trifecta (WIT <25 min, negative surgical margin and absence of complications) was achieved in 82% of cases, with a PSM rate of 2% despite increasing complex nephrometry scores, which compares favourably with larger series from internationally renowned centres [6].

So then, with the results of the present study [1], can we say that Novick’s requirements have been met, and that minimally invasive NSS is now a ‘completely integrated option’? Certainly, with the widespread adoption of robot-assisted surgery, high-quality outcomes are within the grasp of centres other than elite academic institutions. As techniques develop and experience grows robot-assisted surgery can be increasingly offered, even for resection of more complex tumours.

To ensure that minimally invasive NSS is delivered to the highest standards, it will be necessary for providers to ensure both quality assurance and quality control in their processes. The learning curve needs to be minimised with structured teaching and mentoring, and the use of adjuncts such as intraoperative ultrasonography or fluorescence should be a routine part of care.

Centres offering this technique should be mindful of the well documented volume–outcome relationship that appears to be ubiquitous among complex surgical procedures. If centres are performing less than an optimum number of cases, they may consider affiliating themselves with other such centres in networks and forming a joint clinical governance programme, as has been described for robot-assisted radical prostatectomy and which has shown demonstrable improvements in outcomes.

Finally, auditing and reporting of outcomes remains the cornerstone of quality assurance as shown by the introduction of the BAUS complex surgery audit, which is intended to drive standards of care forward. Publications such as that of Veeratterapillay et al. [1] greatly assist in documenting the progress of new techniques and emerging technologies. Increasingly, patients expect transparency from healthcare providers, and with the necessary support processes in place, such initiatives, and the data that they produce will help to further improve the delivery of complex surgery to patients from all areas of our practice.

Benjamin W. Lamb* and Daniel A. Moon*

 

*Division of Cance r Surgery, Peter MacCallum Cancer Centre, Epworth Healthcare, and Department of Surgery, Central Clinical School, Monash University, Melbourne, Vic., Australia

 

References

 

1 Veeratterapillay R, Addla SK, Jelley C et al. Early surgical outcomes and oncological results of robot-assisted partial nephrectomy: a multicentre study. BJU Int 2017; 120: 5505

 

2 Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 2001; 166: 618

 

3 Polascik TJ, Pound CR, Meng MV, Partin AW, Marshall FF. Partial nephrectomy: technique, complications and pathological ndings. J Urol 1995; 154: 131218

 

4 Gill IS, Meraney AM, Schweizer DK et al. Laparoscopic radical nephrectomy in 100 patients. Cancer 2001; 92: 184355

 

5 Novick AC. Laparoscopic and partial nephrectomy. Clin Cancer Res 2004; 10: 6322S7S

 

 

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