Robot‐assisted partial nephrectomy for sporadic ipsilateral multifocal renal tumours

Abstract

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Although laparoscopic excision of ipsllateral multifocal renal tumours is feasible, the average warm ischemia time is prolonged. Robotic partial nephrectomy in this subset of patients using blunt dissection to enucleate the tumour is feasible and safe. This study demonstrates further that robot‐assisted partial nephrectomy with a small margin of normal tissue is feasible and safe with an acceptable range of warm ischemia time in patients with sporadic ipsilateral multifocal renal tumours. This study also suggest that robotic partial nephrectomy for this particular group of patients may better preserve renal function compared to laparoscopic approach, however this needs to be confirmed with prospective comparative studies. OBJECTIVE • To report our short‐term results of robot‐assisted partial nephrectomy for treating sporadic multiple ipsilateral renal tumours. METHODS • Over a 3‐year period, eight patients with two or more ipsilateral renal masses underwent nine robotic partial nephrectomies in our institution. • We evaluated the PADUA and R.E.N.A.L. nephrometry scores, intraoperative outcomes, histopathological characteristics, complications according to Clavien classification and renal function outcomes. RESULTS • In total, 19 tumours were removed from eight patients in nine procedures. Mean operative time was 199 ± 47 min (median 200; range 150–300). Mean size of the dominant lesion was 3.0 ± 1.1 cm (2.7; 1.6–4.8) and overall mean tumour size was 2.2 ± 1.2 cm (1.9; 0.4–4.8). Mean number of tumours removed per patient was 2.4. • Median PADUA and R.E.N.A.L. scores were 7 and 6 (with the predominance of an anterior, non‐hilar position), respectively. • Excluding the six off‐clamp resected tumours, the mean warm ischaemia time was 21 ± 9.2 min (21; 10–35). Mean estimated blood loss was 250 ± 154 mL (200; 100–500) and no patient required transfusion. There were no intraoperative complications or conversion to open surgery. One patient had atrial fibrillation, resolved with anti‐arrhythmic drugs. Mean length of stay was 4.2 ± 0.97 days. • Sixteen of the nineteen tumours were malignant, most of papillary type and Fuhrman grade II. • The mean decrease in glomerular filtration rate was 4%, with a mean follow‐up of 14 months. CONCLUSIONS • Robotic partial nephrectomy for sporadic ipsilateral multifocal renal tumours is feasible and safe. • Off‐clamp resection of multiple tumours can also be safely performed in carefully selected lesions.

Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results

“…RAPN may overcome the technical limitations of LPN due to three-dimensional visualization associated with the EndoWrist Ò technology that allows for excellent vision of the operative field and the possibility of dissecting the tissue optimally by varying the degree of incidence with the target structures [10][11][12][13][14][15]. Moreover, we confirm at least in cT1a that RAPN can provide equivalent oncological results to LPN with the further advantage of significantly lower the need for clamping, WIT, EBL, and LOS [11,20].…”

“…The 3D vision and the EndoWrist Ò also help to decrease the PSM as they typically provide optimal dissection angles [10][11][12][13][14][15]. Moreover, a faster and precise removal step, without the need of repositioning the kidney to achieve an incidental angle, that is mandatory during LPN, allows the surgeon to perform a more ergonomic and 'intuitive' tumorectomy and to approach even more difficult cases, such as large, intraparenchymal or perihilar tumors [12][13][14][15].…”

“…Moreover, a faster and precise removal step, without the need of repositioning the kidney to achieve an incidental angle, that is mandatory during LPN, allows the surgeon to perform a more ergonomic and 'intuitive' tumorectomy and to approach even more difficult cases, such as large, intraparenchymal or perihilar tumors [12][13][14][15]. In these latter cases, when the depth of the lesion or the proximity to important vascular structures makes the procedure more challenging, the adoption of the SE technique can be decisive, as the blunt dissection provides a clear dissection plane identification, helping the surgeon to discriminate the natural cleavage plane existing between the tumor and the renal parenchyma, and ''to stay close'' to the pseudocapsule allows the surgeon to avoid entering into the tumor.…”

“…Early feasibility studies have demonstrated that RAPN provides equivalent oncological results to LPN with the further advantage of significantly lower intraoperative blood loss, reduced hospital stay, and WIT [11]. Recent studies have also shown that RAPN can be effectively utilized for the treatment of larger renal tumors that are over 4 cm in diameter and in cases of parahilar lesions [12][13][14][15]. Indeed, the 3D vision associated with the 'endowrist' technology allows for excellent vision of the operative field and the possibility of dissecting the tissue optimally by varying the degree of incidence with the target structures.…”

Challenging situations in partial nephrectomy

“…On the other hand some surgeons elect to operate on less complicated tumour first. Laparoscopic and robotic techniques have been shown to be feasible in treating multiple renal tumours however their use must not come at the expense of oncological clearance [34,35].…”