-
Clinical Imaging Aug 2021To evaluate the safety and efficacy of preoperative renal artery embolization of renal cell carcinoma in reducing intraoperative blood loss during subsequent partial... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate the safety and efficacy of preoperative renal artery embolization of renal cell carcinoma in reducing intraoperative blood loss during subsequent partial nephrectomy through a systematic review and meta-analysis of current literature.
MATERIALS AND METHODS
The PubMed database was searched for articles published from 1970 to 2018 describing patients with renal cell carcinoma who underwent partial nephrectomy with and without preoperative embolization of the tumor. Demographic data, procedural techniques, and surgical outcomes were obtained when available. A random-effects meta-analysis was performed to determine estimated blood loss in both groups of patients.
RESULTS
The literature search identified 14 relevant articles for systematic review, of which 4 articles provided sufficient data to be included in the meta-analysis. 270 patients (173 males, 97 females) underwent partial nephrectomy for RCC, of whom 222 received pre-operative embolization. There were 48 patients in our cohort that underwent partial nephrectomy for RCC without preoperative embolization. Random-effects meta-analysis demonstrated a significant difference between EBL in patients undergoing RAE prior to partial nephrectomy vs partial nephrectomy without preoperative embolization, with EBL of 154.0 ± 22.6 mL (n = 222) and 353.4 ± 69.6 mL (n = 478), respectively (p < 0.0001). Major complications occurred in 4.9% of patients undergoing pre-operative embolization followed by partial nephrectomy, whereas major complications occurred in 10.9% of patients undergoing partial nephrectomy without embolization (p = 0.01). Minor complications occurred in 5.8% of patients undergoing embolization and partial nephrectomy and in 19.0% of patients undergoing partial nephrectomy without embolization (p < 0.0001).
CONCLUSION
Renal artery embolization prior to surgical resection of renal cell carcinoma is safe and significantly reduces intraoperative blood loss in patients undergoing partial nephrectomy.
Topics: Carcinoma, Renal Cell; Embolization, Therapeutic; Female; Humans; Kidney Neoplasms; Male; Nephrectomy; Renal Artery; Treatment Outcome
PubMed: 33964598
DOI: 10.1016/j.clinimag.2021.04.021 -
European Urology May 2015Robotic partial nephrectomy (RPN) is rapidly increasing; however, the benefit of RPN over laparoscopic partial nephrectomy (LPN) is controversial. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Robotic partial nephrectomy (RPN) is rapidly increasing; however, the benefit of RPN over laparoscopic partial nephrectomy (LPN) is controversial.
OBJECTIVE
To compare perioperative outcomes of RPN and LPN.
EVIDENCE ACQUISITION
We searched Ovid-Medline, Ovid-Embase, the Cochrane Library, KoreaMed, KMbase, KISS, RISS, and KisTi from their inception through August 2013. Two independent reviewers extracted data using a standardized form. Quality of the selected studies was assessed using the methodological index for nonrandomized studies.
EVIDENCE SYNTHESIS
A total of 23 studies and 2240 patients were included. All studies were cohort studies with no randomization, and the methodological quality varied. There was no significant difference between the two groups regarding complications of Clavien-Dindo classification grades 1-2 (p=0.62), Clavien-Dindo classification grades 3-5 (p=0.78), change of serum creatinine (p=0.65), operative time (p=0.35), estimated blood loss (p=0.76), and positive margins (p=0.75). The RPN group had a significantly lower rate of conversion to open surgery (p=0.02) and conversion to radical surgery (p=0.0006), shorter warm ischemia time (WIT; p=0.005), smaller change of estimated glomerular filtration rate (eGFR; p=0.03), and shorter length of stay (LOS; p=0.004).
CONCLUSIONS
This meta-analysis shows that RPN is associated with more favorable results than LPN in conversion rate to open or radical surgery, WIT, change of eGFR, and shorter LOS. To establish the safety and effectiveness outcomes of robotic surgery, well-designed randomized clinical studies with long-term follow-up are needed.
PATIENT SUMMARY
Robotic partial nephrectomy (PN) is more favorable than laparoscopic PN in terms of lower conversion rate to radical nephrectomy, a favorable renal function indexed estimated glomerular filtration rate, shorter length of hospital stay, and shorter warm ischemia time.
Topics: Conversion to Open Surgery; Glomerular Filtration Rate; Humans; Laparoscopy; Length of Stay; Nephrectomy; Operative Time; Robotic Surgical Procedures; Robotics; Treatment Outcome; Warm Ischemia
PubMed: 25572825
DOI: 10.1016/j.eururo.2014.12.028 -
Minerva Urology and Nephrology Dec 2023In the absence of consensus on the optimal approach to renorrhaphy in partial nephrectomy, this systematic review aims to assess the various renorrhaphy techniques and...
INTRODUCTION
In the absence of consensus on the optimal approach to renorrhaphy in partial nephrectomy, this systematic review aims to assess the various renorrhaphy techniques and their impact on surgical outcomes.
EVIDENCE ACQUISITION
A systematic review of the literature was performed in March 2022, using PubMed and Scopus, without time restrictions and research filters for studies investigating renorrhaphy techniques in partial nephrectomy. Studies providing sufficient details on renorrhaphy techniques and their outcomes during minimally invasive partial nephrectomy (PN) were included in this analysis.
EVIDENCE SYNTHESIS
Thirty-one studies with 5720 patients were included in the analysis. In most studies, tumor diameter was <4 cm. RENAL and PADUA scores as well as tumor locations were heterogeneous between the studies. The results of the use of hemostatic agents were conflicting among different studies with limited evidence regarding the benefits of its routine use in partial nephrectomy. The use of barbed and running sutures was associated with a reduced warm ischemia time. While some studies showed a decreased warm ischemia time when omitting cortical renorrhaphy, others found that it may lead to higher incidence of minor complications without any significant improvement in other outcomes.
CONCLUSIONS
There is ongoing research to determine the optimal approach to renorrhaphy. The current evidence on the routine use of hemostatic agents is limited. The use of certain techniques such as barbed sutures, sliding clips and running sutures reduced the warm ischemia time. The omission of cortical renorrhaphy is still controversial.
Topics: Humans; Kidney Neoplasms; Suture Techniques; Nephrectomy; Kidney; Hemostatics
PubMed: 38126283
DOI: 10.23736/S2724-6051.23.05345-4 -
World Journal of Surgical Oncology Aug 2016Robot-assisted partial nephrectomy (RAPN) has been widely used worldwide, to determine whether RAPN is a safe and effective alternative to open partial nephrectomy (OPN)... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Robot-assisted partial nephrectomy (RAPN) has been widely used worldwide, to determine whether RAPN is a safe and effective alternative to open partial nephrectomy (OPN) via the comparison of RANP and OPN.
METHODS
A comprehensive literature search was performed within the databases including PubMed, Cochrane Library, and Embase updated on 30 September 2015. Summary data with their corresponding 95 % confidence intervals (CIs) were calculated using a random effects or fixed effects model. Heterogeneity and publication bias were also evaluated.
RESULTS
A total of 16 comparative studies including 3024 cases were used for this meta-analysis. There are no significant differences in the demographic characteristic between the two groups, but the age was lower and the tumor size was smaller for the RAPN group. RAPN had a longer operative time and warm ischemia time but which showed less estimated blood loss, hospital stay, and perioperative complications. No differences existed in the margin status, the change of glomerular filtration rate, transfusion rate, and conversion rate between the two groups. There was no significant publication bias.
CONCLUSIONS
RAPN offered a lower rate of perioperative complications, less estimated blood loss, and shorter length of hospital stay than OPN, suggesting that RAPN can be an effective alternative to OPN. Well-designed prospective randomized controlled trials will be helpful in validating our findings.
Topics: Blood Component Transfusion; Blood Loss, Surgical; Conversion to Open Surgery; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Length of Stay; Margins of Excision; Nephrectomy; Operative Time; Robotic Surgical Procedures; Treatment Outcome; Warm Ischemia
PubMed: 27549155
DOI: 10.1186/s12957-016-0971-9 -
Current Urology Reports Feb 2021To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the...
PURPOSE
To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed.
FINDINGS
There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.
Topics: Cystectomy; Endoscopy; Humans; Imaging, Three-Dimensional; Kidney Pelvis; Learning Curve; Nephrectomy; Prostatectomy; Plastic Surgery Procedures; Robotic Surgical Procedures; Ureter; Urinary Bladder; Urologic Diseases; Urologic Surgical Procedures
PubMed: 33554322
DOI: 10.1007/s11934-021-01040-2 -
BJU International Apr 2023To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that... (Review)
Review
OBJECTIVES
To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that the weighted pooled peri-operative mortality rate will be <10%.
METHODS
Searches were performed of the Cochrane, Embase and Medline databases and the grey literature for studies published during the period 1 January 2000 to 30 August 2021. Eligible studies reported cohorts of ≥10 predominantly adult patients with XGP and described either average patient age or mortality rate.
RESULTS
In total, 40 eligible studies were identified, representing 1139 patients with XGP. There were 18 deaths, with a weighted pooled peri-operative mortality rate of 1436 per 100 000 patients. The mean age was 49 years, 70% of patients were female and 28% had diabetes mellitus. The left kidney was more commonly affected (60%). Four patients had bilateral XGP, and all of whom survived. Renal or ureteric stones were present in 69% of patients, including 48% with staghorn calculi. Urine culture was positive in 59% of cases. Fistulae were present in 8%. Correct preoperative diagnosis occurred in only 45% of patients. Standard treatment continues to comprise a short cause of antibiotics and open radical (total) nephrectomy. Preoperative decompression occurred in 56% of patients. When considered at all, laparoscopic nephrectomy was performed in 34% of patients. Partial nephrectomy was conducted in 2% of patients.
CONCLUSIONS
Xanthogranulomatous pyelonephritis has a lower mortality rate than historically reported. A typical patient is a woman in her fifth or sixth decade of life with urolithiasis. While open radical nephrectomy remains the most common treatment method, laparoscopic, and to a lesser degree partial nephrectomy, are feasible in well selected patients.
Topics: Humans; Adult; Female; Middle Aged; Male; Pyelonephritis, Xanthogranulomatous; Retrospective Studies; Nephrectomy; Laparoscopy; Anti-Bacterial Agents
PubMed: 35993745
DOI: 10.1111/bju.15878 -
European Urology Oncology Dec 2022Use of three-dimensional (3D) guidance for nephron-sparing surgery (NSS) has increased in popularity, especially for laparoscopic and robotic approaches. Different 3D... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Use of three-dimensional (3D) guidance for nephron-sparing surgery (NSS) has increased in popularity, especially for laparoscopic and robotic approaches. Different 3D visualization modalities have been developed as promising new tools for surgical planning and intraoperative navigation.
OBJECTIVES
To summarize and evaluate the impact of 3D models on minimally invasive NSS in terms of perioperative, functional, and oncological outcomes.
EVIDENCE ACQUISITION
A systematic literature search was conducted in December 2021 using the Medline (PubMed), Embase (Ovid), Scopus, and Web of Science databases. The protocol was registered on PROSPERO (CRD42022300948). The search strategy used the PICOS (Population, Intervention, Comparison, Outcome, Study design) criteria and article selection was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias and the quality of the articles included were assessed. A dedicated data extraction form was used to collect the data of interest. Meta-analysis was performed using the Mantel-Haenszel method for binary outcomes, with results summarized as the odds ratio (OR), and the inverse variance method for continuous data, with results reported as the mean difference (MD). All effect estimates are reported with the 95% confidence interval (CI) and p ≤ 0.05 was considered statistically significant. All analyses were performed using R software and the meta package.
EVIDENCE SYNTHESIS
The initial electronic search identified 450 papers, of which 17 met the inclusion criteria and were included in the analysis. Use of 3D technology led to a significant reduction in the global ischemia rate (OR 0.22, 95% CI 0.07-0.76; p = 0.02) and facilitated more frequent enucleation (OR 2.54, 95% CI 1.36-4.74; p < 0.01) and less frequent opening of the collecting system (OR 0.36, 95% CI 0.15-0.89; p = 0.03) and was associated with less blood loss (MD 23.1 ml, 95% CI 31.8-14.4; p < 0.01). 3D guidance for NSS was associated with a significant reduction in the transfusion rate (OR 0.20, 95% CI 0.07-0.56; p < 0.01). There were no significant differences in rates of conversion to radical nephrectomy, minor and major complications, change in glomerular filtration rate, or surgical margins (all p > 0.05).
CONCLUSIONS
3D guidance for NSS is associated with lower rates of detriment and surgical injury to the kidney. Specifically, a lower amount of nontumor renal parenchyma is exposed to ischemia or sacrificed during resection, and opening of the collecting system is less frequent. However, use of 3D technology does not lead to significant improvements in oncological or functional outcomes.
PATIENT SUMMARY
We reviewed the use of three-dimensional tools for minimally invasive surgery for partial removal of the kidney in patients with kidney cancer. The evidence suggests that these tools have benefits during surgery, but do not lead to significant improvements in cancer control or functional outcomes for patients.
Topics: Humans; Robotic Surgical Procedures; Treatment Outcome; Nephrectomy; Kidney Neoplasms; Carcinoma, Renal Cell
PubMed: 36216739
DOI: 10.1016/j.euo.2022.09.003 -
European Urology Apr 2017Partial nephrectomy (PN) is the reference standard of management for a cT1a renal mass. However, its role in the management of larger tumors (cT1b and cT2) is still... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Partial nephrectomy (PN) is the reference standard of management for a cT1a renal mass. However, its role in the management of larger tumors (cT1b and cT2) is still under scrutiny.
OBJECTIVE
To conduct a meta-analysis assessing functional, oncologic, and perioperative outcomes of PN and radical nephrectomy (RN) in the specific case of larger renal tumors (≥cT1b). The primary endpoint was an overall analysis of cT1b and cT2 masses. The secondary endpoint was a sensitivity analysis for cT2 only.
EVIDENCE ACQUISITION
A systematic literature review was performed up to December 2015 using multiple search engines to identify eligible comparative studies. A formal meta-analysis was performed for studies comparing PN to RN for both cT1b and cT2 tumors. In addition, a sensitivity analysis including the subgroup of studies comparing PN to RN for cT2 only was conducted. Pooled estimates were calculated using a fixed-effects model if no significant heterogeneity was identified; alternatively, a random-effects model was used when significant heterogeneity was detected. For continuous outcomes, the weighted mean difference (WMD) was used as summary measure. For binary variables, the odds ratio (OR) or risk ratio (RR) was calculated with 95% confidence interval (CI). Statistical analyses were performed using Review Manager 5 (Cochrane Collaboration, Oxford, UK).
EVIDENCE SYNTHESIS
Overall, 21 case-control studies including 11204 patients (RN 8620; PN 2584) were deemed eligible and included in the analysis. Patients undergoing PN were younger (WMD -2.3 yr; p<0.001) and had smaller masses (WMD -0.65cm; p<0.001). Lower estimated blood loss was found for RN (WMD 102.6ml; p<0.001). There was a higher likelihood of postoperative complications for PN (RR 1.74, 95% CI 1.34-2.2; p<0.001). Pathology revealed a higher rate of malignant histology for the RN group (RR 0.97; p=0.02). PN was associated with better postoperative renal function, as shown by higher postoperative estimated glomerular filtration rate (eGFR; WMD 12.4ml/min; p<0.001), lower likelihood of postoperative onset of chronic kidney disease (RR 0.36; p<0.001), and lower decline in eGFR (WMD -8.6ml/min; p<0.001). The PN group had a lower likelihood of tumor recurrence (OR 0.6; p<0.001), cancer-specific mortality (OR 0.58; p=0.001), and all-cause mortality (OR 0.67; p=0.005). Four studies compared PN (n=212) to RN (n=1792) in the specific case of T2 tumors (>7cm). In this subset of patients, the estimated blood loss was higher for PN (WMD 107.6ml; p<0.001), as was the likelihood of complications (RR 2.0; p<0.001). Both the recurrence rate (RR 0.61; p=0.004) and cancer-specific mortality (RR 0.65; p=0.03) were lower for PN.
CONCLUSIONS
PN is a viable treatment option for larger renal tumors, as it offers acceptable surgical morbidity, equivalent cancer control, and better preservation of renal function, with potential for better long-term survival. For T2 tumors, PN use should be more selective, and specific patient and tumor factors should be considered. Further investigation, ideally in a prospective randomized fashion, is warranted to better define the role of PN in this challenging clinical scenario.
PATIENT SUMMARY
We performed a cumulative analysis of the literature to determine the best treatment option in cases of localized kidney tumor of higher clinical stage (T1b and T2, as based on preoperative imaging). Our findings suggest that removing only the tumor and saving the kidney might be an effective treatment modality in terms of cancer control, with the advantage of preserving the kidney function. However, a higher risk of perioperative complications should be taken into account when facing larger tumors (clinical stage T2) with kidney-sparing surgery.
Topics: Blood Loss, Surgical; Carcinoma, Renal Cell; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Neoplasm Recurrence, Local; Neoplasm Staging; Nephrectomy; Postoperative Complications; Renal Insufficiency, Chronic; Treatment Outcome
PubMed: 27614693
DOI: 10.1016/j.eururo.2016.08.060 -
Current Opinion in Urology Mar 2018Various ischemia type during partial nephrectomy for renal cell cancer (RCC) resulted in different postoperative functional outcomes. Our objective was to systematically...
PURPOSE OF REVIEW
Various ischemia type during partial nephrectomy for renal cell cancer (RCC) resulted in different postoperative functional outcomes. Our objective was to systematically review the contemporary literature on robot-assisted partial nephrectomy (RPN) and investigate the association of ischemia type and tumor complexity with postoperative functional outcomes of the operated kidney and overall.
RECENT FINDINGS
Forty-five of the 99 reports identified were selected for qualitative analysis. All included studies were observational and nonrandomized. Overall, we found that patients undergoing RPN with zero ischemia and selective artery clamping had a lower decrease in glomerular filtration rates of the operated kidney in comparison to both warm and cold ischemia. This association seems also to play a role in patients with bilateral kidneys harboring complex tumors.
SUMMARY
Zero ischemia and selective artery clamping provide the best functional outcomes following robotic partial nephrectomy. This seems to be of particular relevance in patients with single kidney or tumors of high complexity. Whether these changes are statistically or clinically significant cannot be determined within this systematic review.
Topics: Carcinoma, Renal Cell; Glomerular Filtration Rate; Humans; Ischemia; Kidney; Kidney Neoplasms; Nephrectomy; Observational Studies as Topic; Postoperative Complications; Postoperative Period; Preoperative Period; Radionuclide Imaging; Renal Artery; Retroperitoneal Space; Robotic Surgical Procedures; Solitary Kidney; Treatment Outcome
PubMed: 29278584
DOI: 10.1097/MOU.0000000000000482 -
Journal of Endourology Aug 2015To compare the clinical efficacy and safety of selective vs hilar clamping during minimally invasive partial nephrectomy (PN). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To compare the clinical efficacy and safety of selective vs hilar clamping during minimally invasive partial nephrectomy (PN).
METHODS
Studies comparing the effect and safety of selective versus hilar clamping during PN were identified by a systematic search using MEDLINE and EMBASE from January 2000 to November 2014. Quality of the selected studies was assessed according to the Newcastle-Ottawa Scale (NOS).
RESULTS
A total of seven retrospective studies were included. No significant differences were observed between the two groups in age, body mass index, tumor size, pre-estimated glomerular filtration rate (eGFR), operative time, and length of stay. The selective clamping group had greater estimated blood loss (P<0.01) but similar blood transfusion rate (P=0.78) compared with the hilar clamping group. There were no significant differences between the two groups in terms of urinary leaks, overall complication rate, and positive margin rate. Patients who underwent selective clamping had a lower change in eGFR (mean difference [MD]: 13.95; 95% CI 8.85 to 19.05; P<0.01) and a lower percent change in eGFR (MD: 18.51; 95% CI 14.18 to 22.84; P<0.01) at 1 week. Combined results from two studies showed a trend toward a lower percent change in eGFR at 3 months (MD: 5.47; 95% CI -0.28 to 11.22; P=0.06). At 6 months, two studies showed no significant differences in percent change of renal function between the two groups (MD: 16.85; 95% CI -10.47 to 44.16; P=0.23).
CONCLUSIONS
Although selective clamping resulted in greater estimated blood loss, it provided comparable perioperative safety and superior short-term renal function preservation. The advantage of selective clamping in preservation of intermediate-term renal function remains to be evaluated in the future, however. There is a need for properly designed studies to confirm our founding.
Topics: Blood Loss, Surgical; Constriction; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Minimally Invasive Surgical Procedures; Nephrectomy; Operative Time; Retrospective Studies
PubMed: 25746718
DOI: 10.1089/end.2014.0878