Platinum Correspondence

Margin, Ischemia, and Complications (MIC) Score in Partial Nephrectomy: A New System for Evaluating Achievement of Optimal Outcomes in Nephron-sparing Surgery

To compare the perioperative outcomes of patients with complex renal tumors treated with open versus robot-assisted partial nephrectomy.

This retrospective study included 273 patients diagnosed with localized renal tumors at our institution between January 2007 and October 2020. Patients with moderate to high complexity tumors based on the RENAL nephrometry score were included. Perioperative outcomes were compared between open and robot-assisted partial nephrectomy patients. Remnant renal function was defined as the estimated glomerular filtration rate at 12 months after surgery.

Open and robot-assisted partial nephrectomy were performed in 43 and 77 patients, respectively. There was no significant difference in overall, cancer-specific, recurrence-free, and metastasis-free survival between the two groups. Remnant renal function was significantly better preserved in the open group, and body mass index was identified as an independent predictive factor (odds ratio 3.05, P = 0.017). Ischemia or type of surgery were not related to remnant renal function. The trifecta achievement rate was 51.2% in the open group and 71.4% in the robot-assisted group (P = 0.031), and the incidence of complications was significantly higher in the open partial nephrectomy group (P = 0.0030). Multivariate analysis revealed that open partial nephrectomy was an independent predictive factor for the incidence of complications (odds ratio 3.92, P = 0.0020).

Robot-assisted partial nephrectomy can provide good and acceptable oncological and functional outcomes with fewer complications in patients with more complex renal tumors. Further research is needed to establish appropriate treatment strategies and guidelines in current clinical practice.

Robot-assisted partial nephrectomy (RAPN) is a challenging procedure that is influenced by a multitude of factors.

To assess the impact of prior surgical experience on perioperative outcomes in RAPN.

In this retrospective multicenter study, results for 2548 RAPNs performed by 25 surgeons at eight robotic referral centers were analyzed. Perioperative data for all consecutive RAPNs from the start of each individual surgeon’s experience were collected, as well as the number of prior open or laparoscopic kidney surgeries, pelvic surgeries (open, laparoscopic, robotic), and other robotic interventions.

Transperitoneal or retroperitoneal RAPN.

The impact of prior surgical experience on operative time, warm ischemia time (WIT), major complications, and margin, ischemia, complication (MIC) score (negative surgical margins, WIT ≤20 min, no major complications) was assessed via univariate and multivariable regression analyses accounting for age, gender, body mass index (BMI), American Society of Anesthesiologists score, PADUA score, and RAPN experience.

BMI, PADUA score, and surgical experience in RAPN had a strong impact on perioperative outcomes. A plateau effect for the learning curve was not observed. Prior laparoscopic kidney surgery significantly reduced the operative time (p < 0.001) and WIT (p < 0.001) and improved the MIC rate (p = 0.022). A greater number of prior robotic pelvic interventions decreased WIT (p = 0.011) and the rate of major complications (p < 0.001) and increased the MIC rate (p = 0.011), while prior experience in open kidney surgery did not. One limitation is the short-term follow-up.

Mastering of RAPN is an ongoing learning process. However, prior experience in laparoscopic kidney and robot-assisted pelvic surgery seems to improve perioperative outcomes for surgeons when starting with RAPN, while experience in open surgery might not be crucial.

In this multicenter analysis, we found that a high degree of experience in keyhole kidney surgery and robot-assisted pelvic surgery helps surgeons in achieving good initial outcomes when starting robot-assisted kidney surgery.

To evaluate whether a 2-dimensional(2D) model describes the surgical difficulty of a renal mass accurately comparable to that obtained using a 3D model with the Simplified PADUA REnal nephrometry system (SPARE).

A total of 100 patients underwent RAPN in our hospital between October 2018 and May 2021. We excluded patients with CT images inappropriate for evaluation or for construction of 3D models, patients with multiple tumors, and those who underwent preoperative transcatheter arterial embolization. We conducted a retrospective analysis of the remaining patients using SPARE predictions from CT images (2D-SPARE) and SPARE predictions from 3D models (3D-SPARE). We evaluated the difference between the 2 nephrometry scores and compared them by their ability to predict the achievement of the desired surgical outcome: absence of positive margins, absence of ischemia, and absence of significant complications.

A total of 87 patients were included in this study. Total score, and risk categorization using 3D-SPARE was significantly different from those using 2D-SPARE (P <.05), but in their areas under the curve (AUC), the scores and categorizations were not significantly different (score, 0.763 vs 0.742; P = .501; categorization, 0.711 vs 0.701; P = .755).

The SPARE system can describe the surgical difficulty of renal masses with high accuracy even without the use of 3D renal models.

The aim of the study was to evaluate three-dimensional virtual models (3DVMs) usefulness in the intraoperative assistance of minimally-invasive partial nephrectomy in highly complex renal tumors.

At our institution cT1-2N0M0 all renal masses with Preoperative Aspects and Dimensions Used for an Anatomical classification score ≥10 treated with minimally-invasive partial nephrectomy were considered for the present study. For inclusion a baseline contrast-enhanced computed tomography in order to obtain 3DVMs, the baseline and postoperative serum creatinine as well as estimated glomerular filtration rate values were needed. These patients, in which 3DVMs were used to assist the surgeon in the planning and intraoperative guidance, were then compared with a control group of patients who underwent minimally-invasive partial nephrectomy with the same renal function assessments, but without 3DVMs. Multivariable logistic regression models were used to predict the margin, ischemia, and complication score achievement.

Overall, 79 patients met the inclusion criteria and were compared with 143 complex renal masses without 3DVM assistance. The 3DVM group showed better postoperative outcomes in terms of baseline-weighted differential estimated glomerular filtration rate (−17.7% vs. −22.2%, p=0.03), postoperative complications (16.5% vs. 23.1%, p=0.03), and major complications (Clavien Dindo >III, 2.5% vs. 5.6%, p=0.03). At multivariable logistic regression 3DVM assistance independently predicted higher rates of successful partial nephrectomy (odds ratio: 1.42, p=0.03).

3DVMs represent a useful tool to plan a tailored surgical approach in case of surgically complex masses. They can be used in different ways, matching the surgeon's needs from the planning phase to the demolitive and reconstructive phase, leading towards maximum safety and efficacy outcomes.

With increasing acceptance of robotic partial nephrectomy over the last decade, there is an ongoing discussion about the transperitoneal versus retroperitoneal access.

To report outcomes after transperitoneal (TRPN) versus retroperitoneal (RRPN) robotic partial nephrectomy.

A total of 754 patients were identified from the databases of three high-volume centers who underwent either TRPN (n = 551) or RRPN (n = 203).

Perioperative data were evaluated retrospectively. A propensity score matched-pair analysis was performed with the following variables: grade of renal insufficiency, age, body mass index, tumor diameter, and preoperative aspects and dimensions used for an anatomical (PADUA) score with a subsequent subgroup analysis for tumor location. For quality outcomes, the margin, ischemia, and complications (MIC) criteria were used (negative margins, ischemia time <20 min, and no major complications). Statistical analyses included chi-square and Mann-Whitney U tests.

In all, 176 patients could be matched in each group. The median tumor diameter was 28 mm with a PADUA score of 9. In 11% of RRPN versus 44% of TRPN cases, an anterior tumor location was found, and in 55% versus 30%, a posterior lesion was found (p < 0.001). Operative time (119 vs 139 min, p < 0.001) and warm ischemia time (9 vs 10 min, p = 0.003) were significantly shorter for RRPN. No significant differences were observed between intra- and postoperative complication rates, with 8% major complications in TRPN versus 3% in RRPN (p = 0.06). The MIC criteria were achieved in 90% in the RRPN versus 88% in the TRPN group, without differences for tumor location.

Significant differences between TRPN and RRPN could be found for intraoperative time, while complication rates and quality outcomes were comparable. RRPN can also be a considerable alternative for anterior tumors.

In this study, we demonstrate that robotic partial nephrectomy is feasible with either a transperitoneal or a retroperitoneal surgical access. The posterior approach can also be used for anterior renal tumors and may result in shorter operative time.