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187 LAPAROSCOPIC PARTIAL NEPHRECTOMY VERSUS ROBOT ASSISTED PARTIAL NEPHRECTOMY FOR RENAL TUMORS: A SINGLE -INSTITUTIONAL ANALYSIS OF PERIOPERATIVE OUTCOMES
WI time as well as change in serum creatinine and GFR. As such we sought to determine whether the NS correlated with a higher risk of ischaemic renal injury, thus identifying patients who may be at higher risk of renal dysfunction. Materials & Methods: We retrospectively reviewed the perioperative and renal functional outcomes of 61 consecutive robot-assisted partial nephrectomy cases performed by a single robotic surgeon between May 2009 and October 2010. All patients underwent renal artery clamping, tumour resection under warm ischaemia and sutured renorrhaphy. Results: The operative and WI times, blood loss and change in serum creatinine and GFR as compared to NS are displayed in the table below. RENAL NS
No
OR Time
EBL (mls)
WI Time
Δ Cr
Δ GFR
4
7
201.4
60.7
22.7
-0.11
-9.1
5
19
211.1
89.5
17.7
0.02
-1.6
6
10
222.5
100
20
0.22
-15.7
7
10
212.5
95
28.7
0.19
-16.4
8
2
157.5
112.5
26.5
0.04
-4.5
9
5
198
80
24.5
0.03
-2
10
1
180
100
30
0
0
Insufficient data
7
No statistically significant correlation was shown for all factors as defined as a p-value > 0.05 by standard T-test. Conclusions: In our study of robot-assisted partial nephrectomy, we found no significant correlation between the NS, operative time, WI time, blood loss or renal functional outcomes. These findings may suggest that the ergonomics provided by wristed robotic instrumentation may overcome the relative difficulty posed by tumours of higher NS. On the other hand, potential confounders for this study include the relative small numbers especially of low and high nephrometry score, improved perioperative outcomes associated with learning curve phenomenon and the reliance on accurate imaging interpretation to determine the NS. Larger series are required to assess whether NS has any value in predicting those patients who are at greatest risk of renal ischaemic injury following robot-assisted partial nephrectomy.
186
Does robotic partial nephrectomy shorten warm ischemia time? An analysis of ischemia time kinetics
to bias the apparent improvement in WIT. Studies evaluating WIT should account for such influence of the learning curve when analyzing the results of technical advances.
187
Laparoscopic partial nephrectomy versus robot assisted partial nephrectomy for renal tumors: A single -institutional analysis of perioperative outcomes
Hoff J.R., Berg R.E., Wessel N., Berge V. Oslo University Hospital, Dept. of Urology, Aker, Oslo, Norway Introduction & Objectives: To compare perioperative outcomes for laparoscopic partial nephrectomy (LPN) with robot assisted partial nephrectomy (RAPN). Materials & Methods: We performed a retrospective review, evaluating 30 consecutive LPN procedures and 18 consecutive RAPN procedures performed at our institution between 2006 and 2010. Perioperative data were recorded along with pathological outcomes Results: The mean age at operation was 56.0 years (range 33-77 years) and 60.1 years (range 34-79 years) in the LPN and RAPN groups, respectively (p=0.3). There was eighteen (60%) and eleven (61%) male patients (p=0.3) and 11 (37%) and 10 (56%) left kidneys treated (p=0.2) in the LPN and RAPN, respectively. Methods of hilar control were not significant different between the groups. The mean operation time was 163 minutes (range 84-306 minutes) versus 126 minutes (range 90-170 minutes) (p=0.03) and mean warm ischemia time was 24 minutes (range 11-39 minutes) versus 17 minutes (range 8-32 minutes) (p=0.01) in the LPN and RAPN groups, respectively. Mean estimated blood loss (EBL) was 305 ml (range 0-1300 ml) and 112 ml (range 0-400 ml) (p=0.03) in the LPN and RAPN groups, respectively, but no statistical significant difference in patients receiving blood transfusions (10% vs. 6 %). There was one intraoperative complication only in the LPN group, and 3 and 1 postoperative complications requiring reoperation in the LPN and RAPN group, respectively (p=0.6). Comparison of mean pathological tumor size (29 mm vs. 31 mm), positive margin rate (23% vs. 11%) and days at hospital (4.6 days vs. 4.4 days) revealed no statistical significant difference. The pathological examination showed malignant histology in 67% of patients in both groups. Conclusions: RAPN is a safe and viable alternative to LPN, providing equivalent early oncological outcomes. Moreover, RAPN appears to offer significant shorter operation time, warm ischemia time and reduced EBL
188
Robot-Assisted Partial Nephrectomy (RAPN). Experience in 60 cases
Matin S.F., Messetti F., Du K., Wood G. MD Anderson Cancer Center, Dept. of Urology, Houston, United States of America
Barbier E., Theveniaud P.E., Eschwege P., Hubert J. CHU Nancy-Brabois, Dept. of Urology, Vandœuvre les Nancy, France
Introduction & Objectives: Robotic assisted partial nephrectomy (RAPN) has recently been reported to improve the outcomes of laparoscopic partial nephrectomy (LPN) by possible reduction of warm ischemia time (WIT). We evaluate individual time kinetics of steps during RPN and LPN to determine if WIT is shortened, and if so, which steps are facilitated by the robotic approach. Materials & Methods: A retrospective analysis was performed from a prospectively maintained database of patients undergoing LPN and RAPN. Data that was prospectively documented included WIT, as well as the individual steps during WIT, including tumor excision (EXC), suturing of intrarenal vessels and collecting system (INTRA), and renorrhaphy over a bolster of oxidized cellulose (REN). Other standard demographic and perioperative data, including renal function (estimated glomerular filtration rate using MDRD) preoperatively and at 1 month postoperatively, estimated blood loss (EBL), and length of hospital stay (LOS) were analyzed. Analysis between groups was performed using the Mann Whitney test, and significance was set at p<0.05. Results: Of 208 patients in the database, 170 had undergone LPN, after which 45 RPN were performed. Baseline demographic parameters were equivalent between groups except that patients undergoing RAPN had higher median GFR (87.7 vs. 73.6, p=0.001). RAPN was associated with reduced median WIT (21.5 vs. 26 min, p=0.0254). EXC time was not different (7 vs. 6 min, p=0.2186), but INTRA (7 vs. 10 min, p=0.0102) and REN time (7 vs. 9min, p=0.0418) were significantly better with RAPN. However, an analysis of WIT for all cases demonstrated a continuous reduction over time, even after 100 cases. In order to more accurately determine if these differences were due to use of robotic technology or secondary to other processes, we repeated the analysis but using only the last 50 cases of LPN. In this analysis, WIT was not significantly different (23 min LPN vs. 21.5 min RPN, p=0.9175), and neither were the individual components although INTRA showed a trend toward significance 10 min LPN vs. 7 min RPN, p=0.0638). Differences in EBL, LOS, operative time, change in renal function at 1 month, and positive margin rates (2.6 and 2.3%) were not statistically significant between the 2 groups. Conclusions: RPN was associated with a shorter WIT when evaluating the whole cohort. The time required for tumor excision was not reduced, but the time required for suturing intrarenal vessels, collecting system, and renorrhaphy is significantly shortened. When analyzing only the most recent patients, however, these differences were not seen. There is a significant influence of the learning curve, which includes improved techniques and refinement in patient selection, that seem
Introduction & Objectives: Laparoscopic partial nephrectomy (LPN) is an accepted alternative to open partial nephrectomy but requires a steep learning curve and is still a challenging procedure that only leading teams have developed routinely. Robotics may improve the different operative steps and allow to perform it more easily and in more complex cases. We report our 5 years experience in robotic-assisted LPN (RAPN). Materials & Methods: From 03/05 to 04/10, 60 patients (39 M/21 W; 27 right and 33 left kidneys; mean age 60 yr) underwent RAPN with the DaVinci® system : patients in a 60° flank position, 5 transperitoneal ports were used (2x12, 2x10, 1x5 mm). The artery was clamped with a bulldog before incising the renal parenchyma with the cold scissors. After removing the specimen, 4/0 resorbable stitches were applied to the main vessels and calyx. Complementary sealant (BioGlue®, Tachosil®) was applied to the renal parenchyma, before releasing the clamp. Additional parenchymal suture was applied if necessary. Gerota’s fascia was sutured in order to retroperitonealize the kidney. No suction drain was used. Results: Mean tumor size : 26 mm ; ischemic time 28 min; blood loss was minimal (no transfusion). CT scans performed within the first postoperative week showed no hematoma and good renal function without urinary leak. Histology showed 49 carcinomas, 7 oncocytomas, 4 AML. All surgical margins were negative. Complications : thrombo-embolism (2), urinary infection (2). 2 arterial aneurism required selective embolization. At 20 months mean follow-up, no recurrence was observed. Conclusions: Owing to the benefits of 3D vision and the seven degrees of freedom of the instruments offered with robotics, the surgeon can perform complex procedures such as RAPN more easily than in standard laparoscopy. Our promising results need to be confirmed by further comparative series, but robotics may have an impact on partial nephrectomy similar to its impact on prostatectomy.
Eur Urol Suppl 2011;10(2):82
189
Perioperative outcomes of laparoscopic radical nephroureterectomy and regional lymphadenectomy in patients with upper urinary tract urothelial carcinoma after neoadjuvant chemotherapy
Rajput M.Z.1, Kamat A.M.1, Clavell-Hernandez J.1, Siefker-Radtke A.O.2, Grossman H.B.1, Dinney C.P.1, Matin S.F.1
No
OR Time
EBL (mls)
WI Time
Δ Cr
Δ GFR
4
7
201.4
60.7
22.7
-0.11
-9.1
5
19
211.1
89.5
17.7
0.02
-1.6
6
10
222.5
100
20
0.22
-15.7
7
10
212.5
95
28.7
0.19
-16.4
8
2
157.5
112.5
26.5
0.04
-4.5
9
5
198
80
24.5
0.03
-2
10
1
180
100
30
0
0
Insufficient data
7
No statistically significant correlation was shown for all factors as defined as a p-value > 0.05 by standard T-test. Conclusions: In our study of robot-assisted partial nephrectomy, we found no significant correlation between the NS, operative time, WI time, blood loss or renal functional outcomes. These findings may suggest that the ergonomics provided by wristed robotic instrumentation may overcome the relative difficulty posed by tumours of higher NS. On the other hand, potential confounders for this study include the relative small numbers especially of low and high nephrometry score, improved perioperative outcomes associated with learning curve phenomenon and the reliance on accurate imaging interpretation to determine the NS. Larger series are required to assess whether NS has any value in predicting those patients who are at greatest risk of renal ischaemic injury following robot-assisted partial nephrectomy.
186
Does robotic partial nephrectomy shorten warm ischemia time? An analysis of ischemia time kinetics
to bias the apparent improvement in WIT. Studies evaluating WIT should account for such influence of the learning curve when analyzing the results of technical advances.
187
Laparoscopic partial nephrectomy versus robot assisted partial nephrectomy for renal tumors: A single -institutional analysis of perioperative outcomes
Hoff J.R., Berg R.E., Wessel N., Berge V. Oslo University Hospital, Dept. of Urology, Aker, Oslo, Norway Introduction & Objectives: To compare perioperative outcomes for laparoscopic partial nephrectomy (LPN) with robot assisted partial nephrectomy (RAPN). Materials & Methods: We performed a retrospective review, evaluating 30 consecutive LPN procedures and 18 consecutive RAPN procedures performed at our institution between 2006 and 2010. Perioperative data were recorded along with pathological outcomes Results: The mean age at operation was 56.0 years (range 33-77 years) and 60.1 years (range 34-79 years) in the LPN and RAPN groups, respectively (p=0.3). There was eighteen (60%) and eleven (61%) male patients (p=0.3) and 11 (37%) and 10 (56%) left kidneys treated (p=0.2) in the LPN and RAPN, respectively. Methods of hilar control were not significant different between the groups. The mean operation time was 163 minutes (range 84-306 minutes) versus 126 minutes (range 90-170 minutes) (p=0.03) and mean warm ischemia time was 24 minutes (range 11-39 minutes) versus 17 minutes (range 8-32 minutes) (p=0.01) in the LPN and RAPN groups, respectively. Mean estimated blood loss (EBL) was 305 ml (range 0-1300 ml) and 112 ml (range 0-400 ml) (p=0.03) in the LPN and RAPN groups, respectively, but no statistical significant difference in patients receiving blood transfusions (10% vs. 6 %). There was one intraoperative complication only in the LPN group, and 3 and 1 postoperative complications requiring reoperation in the LPN and RAPN group, respectively (p=0.6). Comparison of mean pathological tumor size (29 mm vs. 31 mm), positive margin rate (23% vs. 11%) and days at hospital (4.6 days vs. 4.4 days) revealed no statistical significant difference. The pathological examination showed malignant histology in 67% of patients in both groups. Conclusions: RAPN is a safe and viable alternative to LPN, providing equivalent early oncological outcomes. Moreover, RAPN appears to offer significant shorter operation time, warm ischemia time and reduced EBL
188
Robot-Assisted Partial Nephrectomy (RAPN). Experience in 60 cases
Matin S.F., Messetti F., Du K., Wood G. MD Anderson Cancer Center, Dept. of Urology, Houston, United States of America
Barbier E., Theveniaud P.E., Eschwege P., Hubert J. CHU Nancy-Brabois, Dept. of Urology, Vandœuvre les Nancy, France
Introduction & Objectives: Robotic assisted partial nephrectomy (RAPN) has recently been reported to improve the outcomes of laparoscopic partial nephrectomy (LPN) by possible reduction of warm ischemia time (WIT). We evaluate individual time kinetics of steps during RPN and LPN to determine if WIT is shortened, and if so, which steps are facilitated by the robotic approach. Materials & Methods: A retrospective analysis was performed from a prospectively maintained database of patients undergoing LPN and RAPN. Data that was prospectively documented included WIT, as well as the individual steps during WIT, including tumor excision (EXC), suturing of intrarenal vessels and collecting system (INTRA), and renorrhaphy over a bolster of oxidized cellulose (REN). Other standard demographic and perioperative data, including renal function (estimated glomerular filtration rate using MDRD) preoperatively and at 1 month postoperatively, estimated blood loss (EBL), and length of hospital stay (LOS) were analyzed. Analysis between groups was performed using the Mann Whitney test, and significance was set at p<0.05. Results: Of 208 patients in the database, 170 had undergone LPN, after which 45 RPN were performed. Baseline demographic parameters were equivalent between groups except that patients undergoing RAPN had higher median GFR (87.7 vs. 73.6, p=0.001). RAPN was associated with reduced median WIT (21.5 vs. 26 min, p=0.0254). EXC time was not different (7 vs. 6 min, p=0.2186), but INTRA (7 vs. 10 min, p=0.0102) and REN time (7 vs. 9min, p=0.0418) were significantly better with RAPN. However, an analysis of WIT for all cases demonstrated a continuous reduction over time, even after 100 cases. In order to more accurately determine if these differences were due to use of robotic technology or secondary to other processes, we repeated the analysis but using only the last 50 cases of LPN. In this analysis, WIT was not significantly different (23 min LPN vs. 21.5 min RPN, p=0.9175), and neither were the individual components although INTRA showed a trend toward significance 10 min LPN vs. 7 min RPN, p=0.0638). Differences in EBL, LOS, operative time, change in renal function at 1 month, and positive margin rates (2.6 and 2.3%) were not statistically significant between the 2 groups. Conclusions: RPN was associated with a shorter WIT when evaluating the whole cohort. The time required for tumor excision was not reduced, but the time required for suturing intrarenal vessels, collecting system, and renorrhaphy is significantly shortened. When analyzing only the most recent patients, however, these differences were not seen. There is a significant influence of the learning curve, which includes improved techniques and refinement in patient selection, that seem
Introduction & Objectives: Laparoscopic partial nephrectomy (LPN) is an accepted alternative to open partial nephrectomy but requires a steep learning curve and is still a challenging procedure that only leading teams have developed routinely. Robotics may improve the different operative steps and allow to perform it more easily and in more complex cases. We report our 5 years experience in robotic-assisted LPN (RAPN). Materials & Methods: From 03/05 to 04/10, 60 patients (39 M/21 W; 27 right and 33 left kidneys; mean age 60 yr) underwent RAPN with the DaVinci® system : patients in a 60° flank position, 5 transperitoneal ports were used (2x12, 2x10, 1x5 mm). The artery was clamped with a bulldog before incising the renal parenchyma with the cold scissors. After removing the specimen, 4/0 resorbable stitches were applied to the main vessels and calyx. Complementary sealant (BioGlue®, Tachosil®) was applied to the renal parenchyma, before releasing the clamp. Additional parenchymal suture was applied if necessary. Gerota’s fascia was sutured in order to retroperitonealize the kidney. No suction drain was used. Results: Mean tumor size : 26 mm ; ischemic time 28 min; blood loss was minimal (no transfusion). CT scans performed within the first postoperative week showed no hematoma and good renal function without urinary leak. Histology showed 49 carcinomas, 7 oncocytomas, 4 AML. All surgical margins were negative. Complications : thrombo-embolism (2), urinary infection (2). 2 arterial aneurism required selective embolization. At 20 months mean follow-up, no recurrence was observed. Conclusions: Owing to the benefits of 3D vision and the seven degrees of freedom of the instruments offered with robotics, the surgeon can perform complex procedures such as RAPN more easily than in standard laparoscopy. Our promising results need to be confirmed by further comparative series, but robotics may have an impact on partial nephrectomy similar to its impact on prostatectomy.
Eur Urol Suppl 2011;10(2):82
189
Perioperative outcomes of laparoscopic radical nephroureterectomy and regional lymphadenectomy in patients with upper urinary tract urothelial carcinoma after neoadjuvant chemotherapy
Rajput M.Z.1, Kamat A.M.1, Clavell-Hernandez J.1, Siefker-Radtke A.O.2, Grossman H.B.1, Dinney C.P.1, Matin S.F.1