Category: Laparoscopic/ Robotic: Other
Introduction & Objective :
Partial nephrectomy (PN) on complex tumors is a challenging operation with a higher complication rate. We sought to determine the safety and efficacy of performing PN on patients with high nephrometry score tumors compared to radical nephrectomy.
A multi-institutional kidney cancer database was used to identify patients who underwent RN (n=297, 60.0%) or PN (n=198, 40.0%) for a cT1-cT2a renal mass. Patients with end-stage renal disease or metastatic disease were excluded. PN patients with a R.E.N.A.L. nephrometry score ≥ 10 were used for the analysis. Perioperative outcomes were compared along with renal function, recurrence and overall survival after surgery using multivariable regression models adjusting for patient and tumor-specific variables.
Patients undergoing RN were older (62 vs. 58 years, p=0.001), had a higher Charlson-score (1 vs. 0; p<0.001), were more likely to have hypertension (66.3% vs. 45.9%, p<.001), lower eGFR (79.3 vs. 86.8; p=0.001) and larger tumor size (6.0 vs. 4.3 cm; p<0.001). 15 PN (7%) patients were converted to RN. Adjusting for confounding, multivariable analysis showed that RN was associated with a 78 minute reduction in operative time (p<0.001), a 51% reduction in blood loss (p<0.001) and a 76% reduction in the odds of a positive surgical margin (p=0.017). However, RN was also associated with a 6 times higher likelihood of acute kidney injury (>25% reduction in eGFR) at discharge (p<0.001) and a greater linear decline in eGFR over time (p<0.001). There were no differences in length of stay (p=0.222), post-operative complications (p=0.871), or transfusion rate (p=0.544), recurrence (median follow-up 11.2 months) (p=0.169), or overall survival (median follow-up 13.4 months) (p=0.359).
Conclusions : PN for complex renal tumors is associated with superior functional outcome without an increase in complication or transfusion rates. PN did have a longer operative time and higher estimated blood loss. Our findings suggest that PN should be performed over RN in high nephrometry score tumors when feasible.
Alp Tuna Beksac– Fellow, Icahn School of Medicine at Mount Sinai, New York, New York
David Paulucci– Fellow, Icahn School of Medicine at Mount Sinai, New York, New York
Ronney Abaza– Director - Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio
Daniel Eun– Professor, Temple University, Philadelphia, Pennsylvania
Akshay Bhandari– Professor, Columbia University Division of Urology at Mount Sinai Medical Center, Miami Beach, Florida
Ashok Hemal– Professor , Wake Forest Baptist Medical Center, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
James Porter– Medical Director for Robotic Surgery, Swedish Medical Center, Seattle, Washington
Ketan Badani– Professor of Urology, Icahn School of Medicine at Mount Sinai, New York, New York
Icahn School of Medicine at Mount Sinai
New York, New York
Endourological Society Fellow in Minimally Invasive and Robotic Surgery at Icahn School of Medicine at Mount Sinai.
Director - Robotic Surgery
OhioHealth Dublin Methodist Hospital
Columbia University Division of Urology at Mount Sinai Medical Center
Miami Beach, Florida
Wake Forest Baptist Medical Center
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina
Dr. Hemal is working as a professor in the department of Urology, Comprehensive Cancer Center & Prof., Institute for Regenerative Medicine at Wake Forest Baptist Medical Center. He is well known for his pioneering work in minimally invasive surgery. He has been active in the field of endourology since 1989, laparoscopy since 1992 and robot-assisted surgery since 2001. His contributions to laparoscopic & robot-assisted urologic surgery include the development of new techniques in uro-oncology & commitment to sharing and disseminating knowledge. He has conducted live demonstrations of endourological, laparoscopic & robot-assisted urologic procedures at more than 350 conferences around the world. He has been a visiting professor to more than 350 institutions around the globe to deliver guest lectures and keynote speeches. His trainees have been involved in the establishment of more than 50 minimally invasive programs. He has edited six books & 450 scientific papers and chapters in the book. He is on editorial board of several journals and President of society of robotic urologic surgery.He serves as a member of scientific committee in American Urology Association, World Congress of Endourology & SIU. Dr. Hemal has been the recipient of many academic distinctions and awards. He has been awarded three times by President of India including the most prestigious honor a physician can receive, the “Dr. B.C. Roy Award,” in 2004 for his contributions in the field of cost-effective minimally invasive surgery and highest civilian honor “Padma-Shree” in 2007 for development of robotic urologic surgery. Other prestigious awards to his credit are Urologist of the Decade award, Guest Scholar of the American College of Surgeons, SIU scholar and Fulbright scholar. Dr. Hemal is consistently included in Best Doctors of America, Top Doctors of America, Top Prostate Cancer Specialists and Who’s Who in the World for past several years.
Medical Director for Robotic Surgery
Swedish Medical Center