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BJU International Oct 2023To perform a systematic review and network meta-analysis (NMA) to determine the advantages and disadvantages of open (OPN), laparoscopic (LPN), and robot-assisted... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To perform a systematic review and network meta-analysis (NMA) to determine the advantages and disadvantages of open (OPN), laparoscopic (LPN), and robot-assisted partial nephrectomy (RAPN) with particular attention to intraoperative, immediate postoperative, as well as longer-term functional and oncological outcomes.
METHODS
A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-NMA guidelines. Binary data were compared using odds ratios (ORs). Mean differences (MDs) were used for continuous variables. ORs and MDs were extracted from the articles to compare the efficacy of the various surgical approaches. Statistical validity is guaranteed when the 95% credible interval does not include 1.
RESULTS
In total, there were 31 studies included in the NMA with a combined 7869 patients. Of these, 33.7% (2651/7869) underwent OPN, 20.8% (1636/7869) LPN, and 45.5% (3582/7689) RAPN. There was no difference for either LPN or RAPN as compared to OPN in ischaemia time, intraoperative complications, positive surgical margins, operative time or trifecta rate. The estimated blood loss (EBL), postoperative complications and length of stay were all significantly reduced in RAPN when compared with OPN. The outcomes of RAPN and LPN were largely similar except the significantly reduced EBL in RAPN.
CONCLUSION
This systematic review and NMA suggests that RAPN is the preferable operative approach for patients undergoing surgery for lower-staged RCC.
Topics: Humans; Kidney Neoplasms; Robotics; Network Meta-Analysis; Treatment Outcome; Robotic Surgical Procedures; Nephrectomy; Postoperative Complications; Laparoscopy; Retrospective Studies
PubMed: 37259476
DOI: 10.1111/bju.16093 -
European Urology Focus Jan 2024Partial nephrectomy (PN) with intraoperative guidance by biophotonics has the potential to improve surgical outcomes due to higher precision. However, its value remains... (Review)
Review
CONTEXT
Partial nephrectomy (PN) with intraoperative guidance by biophotonics has the potential to improve surgical outcomes due to higher precision. However, its value remains unclear since high-level evidence is lacking.
OBJECTIVE
To provide a comprehensive analysis of biophotonic techniques used for intraoperative real-time assistance during PN.
EVIDENCE ACQUISITION
We performed a comprehensive database search based on the PICO criteria, including studies published before October 2022. Two independent reviewers screened the titles and abstracts followed by full-text screening of eligible studies. For a quantitative analysis, a meta-analysis was conducted.
EVIDENCE SYNTHESIS
In total, 35 studies were identified for the qualitative analysis, including 27 studies on near-infrared fluorescence (NIRF) imaging using indocyanine green, four studies on hyperspectral imaging, two studies on folate-targeted molecular imaging, and one study each on optical coherence tomography and 5-aminolevulinic acid. The meta-analysis investigated seven studies on selective arterial clamping using NIRF. There was a significantly shorter warm ischemia time in the NIRF-PN group (mean difference [MD]: -2.9; 95% confidence interval [CI]: -5.6, -0.1; p = 0.04). No differences were noted regarding transfusions (odds ratio [OR]: 0.5; 95% CI: 0.2, 1.7; p = 0.27), positive surgical margins (OR: 0.7; 95% CI: 0.2, 2.0; p = 0.46), or major complications (OR: 0.4; 95% CI: 0.1, 1.2; p = 0.08). In the NIRF-PN group, functional results were favorable at short-term follow-up (MD of glomerular filtration rate decline: 7.6; 95% CI: 4.6, 10.5; p < 0.01), but leveled off at long-term follow-up (MD: 7.0; 95% CI: -2.8, 16.9; p = 0.16). Remarkably, these findings were not confirmed by the included randomized controlled trial.
CONCLUSIONS
Biophotonics comprises a heterogeneous group of imaging modalities that serve intraoperative decision-making and guidance. Implementation into clinical practice and cost effectiveness are the limitations that should be addressed by future research.
PATIENT SUMMARY
We reviewed the application of biophotonics during partial removal of the kidney in patients with kidney cancer. Our results suggest that these techniques support the surgeon in successfully performing the challenging steps of the procedure.
PubMed: 38278713
DOI: 10.1016/j.euf.2024.01.005 -
Indian Journal of Urology : IJU :... 2022Multiple studies have been published recently assessing feasibility of robot-assisted partial nephrectomy (RAPN) for moderate to highly complex renal masses. Some... (Review)
Review
INTRODUCTION
Multiple studies have been published recently assessing feasibility of robot-assisted partial nephrectomy (RAPN) for moderate to highly complex renal masses. Some studies have even compared partial nephrectomy (PN) performed through various modalities such as open PN (OPN) versus RAPN and laparoscopic PN (LPN) versus OPN. The primary aim of this review was to analyze perioperative outcomes such as warm ischemia time (WIT), duration of surgery, estimated blood loss (EBL), complications, blood transfusion, length of stay, and margin status following RAPN for complex renal masses. Another objective was to compare perioperative outcomes following various surgical modalities, i.e., OPN, LPN, or RAPN.
METHODS
Literature search was conducted to identify studies reporting perioperative outcomes following RAPN for moderate (Radius, Endophytic/Exophytic, Nearness, Anterior/posterior location [RENAL] score 7-9 or Preoperative Aspects of Dimension used for anatomic classification [PADUA] score 8-9) to high complexity renal masses (RENAL or PADUA score ≥ 10). Meta-analysis of robotic versus OPN and robotic versus LPN was also performed. Study protocol was registered with PROPSERO (CRD42019121259).
RESULTS
In this review, 22 studies including 2,659 patients were included. Mean duration of surgery, WIT, and EBL was 132.5-250.8 min, 15.5-30 min, and 100-321 ml, respectively. From pooled analysis, positive surgical margin, need for blood transfusion, minor and major complications were seen in 3.9%, 5.2%, 19.3%, and 6.3% of the patients. No significant difference was noted between RAPN and LPN for any of the perioperative outcomes. Compared to OPN, RAPN had significantly lower EBL, complications rate, and need for transfusion.
CONCLUSIONS
RAPN for moderate to high complexity renal masses is associated with acceptable perioperative outcomes. LPN and RAPN were equal in terms of perioperative outcomes for complex masses whereas, OPN had significantly higher blood loss, complications rate, and need for transfusion as compared to RAPN.
PubMed: 35983124
DOI: 10.4103/iju.iju_393_21 -
International Journal of Clinical... Apr 2021To investigate the association of adherent perinephric fat (APF) with perioperative outcomes, we conducted a systematic review and meta-analysis of the literature to... (Meta-Analysis)
Meta-Analysis Review
To investigate the association of adherent perinephric fat (APF) with perioperative outcomes, we conducted a systematic review and meta-analysis of the literature to clarify the impact of APF in patients undergoing partial nephrectomy. A systematic literature search using the Medline, Scopus, and Cochrane databases was performed in April 2019 and updated in November 2019 to identify studies investigating the effect of APF on perioperative outcomes in patients treated with partial nephrectomy with the aim of evaluating its impact on intraoperative, postoperative and oncological outcomes. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included studies. A total of 1534 patients in nine nonrandomized, observational studies met our inclusion criteria. Patients with APF were significantly older (p = 0.0001), had a higher BMI (p = 0.0001) and were predominately male (p = 0.003). APF was associated with a higher operative time (p = 0.001) and higher blood loss (p = 0.002). No significant impact of APF was found in terms of postoperative complications, positive margins or length of stay. APF was also found to be associated with malignant renal histology of RCC on final pathology (p = 0.005). APF was associated with some adverse perioperative outcomes, especially a prolonged operating time and higher blood loss. In addition, APF was also associated with underlying renal malignancy, but the precise causal mechanism requires further exploration.
Topics: Adipose Tissue; Body Mass Index; Humans; Kidney; Kidney Neoplasms; Male; Nephrectomy; Postoperative Complications; Robotic Surgical Procedures; Treatment Outcome
PubMed: 33502646
DOI: 10.1007/s10147-021-01871-6 -
Frontiers in Oncology 2023The perioperative, functional, and oncological outcomes of patients with solitary small renal tumors (SRMs) treated with ablation (AT) or partial nephrectomy (PN) remain... (Review)
Review
Perioperative, functional, and oncologic outcomes after ablation or partial nephrectomy for solitary renal tumors: a systematic review and meta-analysis of comparative trials.
OBJECTIVES
The perioperative, functional, and oncological outcomes of patients with solitary small renal tumors (SRMs) treated with ablation (AT) or partial nephrectomy (PN) remain controversial. The aim of this study was to compare the outcomes of these two surgical techniques.
METHODS
In April 2023, we conducted a literature search in several widely used databases worldwide, including PubMed, Embase, and Google Scholar. Review Manager was used to compare various parameters. The study was registered with PROSPERO (CRD42022377157).
RESULTS
Our final meta-analysis included 13 cohort studies with a total of 2,107 patients. Compared to partial nephrectomy (PN), ablation (AT) had shorter hospital stays (WMD -2.37 days, 95% CI -3.05 to -1.69; p < 0.00001), shorter operating times (WMD -57.06 min, 95% CI -88.92 to -25.19; p = 0.0004), less postoperative creatinine increases (WMD -0.17 mg/dL, 95% CI -0.29 to -0.05; p = 0.006), less postoperative glomerular filtration rate decreases (WMD -9.84 mL/min/1.73 m2, 95% CI -14.25 to -5.44; p < 0.0001), less postoperative new-onset chronic kidney disease (OR 0.33, 95% CI 0.16 to 0.71; p = 0.005), and less intraoperative blood loss (WMD -285.92 ml, 95% CI -428.44 to -143.40; p < 0.0001). The transfusion rate was lower in the ablation group (OR 0.17, 95% CI 0.06 to 0.51; p = 0.001). The risk of local recurrence was higher in the ablation group (OR 2.96, 95% CI 1.27 to 6.89; p = 0.01), while the risk of distant metastasis was higher in the partial nephrectomy group (OR 2.81, 95% CI 1.28 to 6.18; p = 0.01). The intraoperative and postoperative complication rates were lower in the ablation group (OR 0.23, 95% CI 0.08 to 0.62; p = 0.004 and OR 0.21, 95% CI 0.11 to 0.38; p < 0.00001, respectively). However, overall survival, postoperative dialysis rate, and tumor-specific survival were not different between the two groups.
CONCLUSIONS
Our data suggest that ablation and partial nephrectomy are equally safe and effective in the treatment of small solitary kidney tumors and are better options for patients with poor preoperative physical condition or poor renal function.
PubMed: 37434978
DOI: 10.3389/fonc.2023.1202587 -
International Braz J Urol : Official... 2022The predictors of trifecta achievement in partial nephrectomy (PN) were poorly inquired and remained a controversial area of discovery. To evaluate predictive factors of... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The predictors of trifecta achievement in partial nephrectomy (PN) were poorly inquired and remained a controversial area of discovery. To evaluate predictive factors of trifecta achievement in patients undergoing PN.
MATERIALS AND METHODS
A systematic literature search was performed to identify relevant articles. Only studies focusing on postoperative trifecta achievement and exploring its predictor with multivariable analyses were included. The trifecta achievement was defined as negative surgical margins, warm ischemia time <25 minutes, and no complications. Merged odds ratio (OR) and 95% confidence interval (CI) were used to evaluate the predictive effect.
RESULTS
Thirteen studies with 7066 patients meeting the inclusion criteria were included. The rate of trifecta achievement ranged from 43.3% to 78.6%. Merged results showed that preoperative eGFR (OR: 1.01, 95% CI: 1.00, 1.02, P=0.02), operative time (OR: 0.99, 95% CI: 0.99, 1.00, P=0.02), estimated blood loss (OR: 1.00, 95% CI: 1.00, 1.00, P <0.001), tumor size (OR: 0.70, 95% CI: 0.58, 0.84, P <0.001), medium (OR: 0.39, 95% CI: 0.18, 0.84, P=0.02) and high PADUA score (OR: 0.23, 95% CI: 0.08, 0.64, P=0.005) were independently associated with trifecta achievement. A publication bias was identified for tumor size. Sensitivity analysis confirmed the stability of result for tumor size.
CONCLUSIONS
Larger tumor size, medium and high PADUA score are associated with decreased probability of trifecta achievement. After verifying by further high-quality studies, these variables can be incorporated into tools to predict probability of trifecta achievement during clinical practice.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34115456
DOI: 10.1590/S1677-5538.IBJU.2021.0095 -
International Journal of Surgery... Jun 2023The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The present study aimed to conduct a pooled analysis to compare the efficacy and safety of minimally invasive partial nephrectomy (MIPN) with open partial nephrectomy (OPN) in patients with complex renal tumors (defined as PADUA or RENAL score ≥7).
METHODS
The present study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, Supplemental Digital Content 1, http://links.lww.com/JS9/A394 . We conducted a systematic search of the PubMed, Embase, Web of Science, and Cochrane Library databases until October 2022. MIPN and OPN-controlled trials for complex renal tumors were included. The primary outcomes were perioperative results, complications, renal function, and oncologic outcomes.
RESULTS
A total of 2405 patients were included in 13 studies. MIPN outperformed OPN in terms of hospital stay [weighted mean difference (WMD) -1.84 days, 95% CI -2.35 to -1.33; P <0.00001], blood loss (WMD -52.42 ml, 95% CI -71.43 to -33.41; P <0.00001), transfusion rates [odds ratio (OR) 0.34, 95% CI 0.17-0.67; P =0.002], major complications (OR 0.59, 95% CI 0.40-0.86; P =0.007) and overall complications (OR 0.43, 95% CI 0.31-0.59; P <0.0001), while operative time, warm ischemia time, conversion to radical nephrectomy rates, estimated glomerular decline, positive surgical margins, local recurrence, overall survival, recurrence-free survival, and cancer-specific survival were not significantly different.
CONCLUSIONS
The present study demonstrated that MIPN was associated with a shorter length of hospital stay, less blood loss, and fewer complications in treating complex renal tumors. MIPN may be considered a better treatment for patients with complex tumors when technically feasible.
Topics: Humans; Postoperative Complications; Treatment Outcome; Kidney Neoplasms; Robotic Surgical Procedures; Nephrectomy
PubMed: 37094827
DOI: 10.1097/JS9.0000000000000397 -
Frontiers in Oncology 2022Minimally invasive partial nephrectomy (MIPN) and focal therapy (FT) are popular trends for small renal masses (SRMs). However, there is currently no systematic...
BACKGROUND
Minimally invasive partial nephrectomy (MIPN) and focal therapy (FT) are popular trends for small renal masses (SRMs). However, there is currently no systematic comparison between MIPN and FT of SRMs. Therefore, we systematically study the perioperative, renal functional, and oncologic outcomes of MIPN and FT in SRMs.
METHODS
We have searched the Embase, Cochrane Library, and PubMed for articles between MIPN (robot-assisted partial nephrectomy and laparoscopic partial nephrectomy) and FT {radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (CA), irreversible electroporation, non-thermal [irreversible electroporation (IRE)] ablation, and stereotactic body radiation therapy (SBRT)}. We calculated pooled mean difference (MD), odds ratios (ORs), and 95% confidence intervals (CIs) (CRD42021260787).
RESULTS
A total of 26 articles (n = 4,420) were included in the study. Compared with MIPN, the operating time (OP) of FT had significantly lower (SMD, -1.20; CI, -1.77 to -0.63; I = 97.6%, P < 0.0001), estimated blood loss (EBL) of FT had significantly less (SMD, -1.20; CI, -1.77 to -0.63; I = 97.6%, P < 0.0001), length of stay (LOS) had shorter (SMD, -0.90; CI, -1.26 to -0.53; I = 92.2%, P < 0.0001), and estimated glomerular filtration rate (eGFR) of FT was significantly lower decrease (SMD, -0.90; CI, -1.26 to -0.53; I = 92.2%, P < 0.0001). However, FT possessed lower risk in minor complications (Clavien 1-2) (OR, 0.69; CI, 0.45 to 1.07; I = 47%, P = 0.023) and overall complications (OR, 0.71; CI, 0.51 to 0.99; I = 49.2%, P = 0.008). Finally, there are no obvious difference between FT and MIPN in local recurrence, distant metastasis, and major complications (P > 0.05).
CONCLUSION
FT has more advantages in protecting kidney function, reducing bleeding, shortening operating time, and shortening the length of stay. There is no difference in local recurrence, distant metastasis, and major complications. For the minimally invasive era, we need to weigh the advantages and disadvantages of all aspects to make comprehensive choices.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier PROSPERO (CRD42021260787).
PubMed: 35692758
DOI: 10.3389/fonc.2022.732714 -
The American Surgeon Jan 2021Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The...
BACKGROUND
Adoption of the robotic surgical platform for small renal cancers has rapidly expanded, but its utility compared to other approaches has not been established. The objective of this review is to assess perioperative and long-term oncologic and functional outcomes of robot-assisted partial nephrectomy (RAPN) compared to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).
METHODS
A search in PubMed, Embase, and Cochrane (2010-2019) was conducted. Of 3877 articles screened, 7 observational studies were included.
RESULTS
RAPN was associated with 24-50 mL less intraoperative blood loss compared to LPN and 39-84 mL less than OPN. RAPN also demonstrated trends of other postoperative benefits, such as shorter length of stay and fewer major complications. Several studies reported better long-term functional kidney outcomes, but these findings were inconsistent. Recurrence and cancer-specific survival (CSS) were similar across groups. While RAPN had a 5-year CSS of 90.1%-97.9%, LPN and OPN had survival rates of 85.9%-86.9% and 88.5-96.3% respectively.
CONCLUSIONS
RAPN may be associated with a lower estimated blood loss and comparable long-term outcomes when compared to other surgical approaches. However, additional randomized or propensity matched studies are warranted to fully assess long-term functional kidney and oncologic outcomes.
Topics: Humans; Kidney Neoplasms; Laparoscopy; Nephrectomy; Robotic Surgical Procedures; Treatment Outcome
PubMed: 32902308
DOI: 10.1177/0003134820948912 -
BJU International Apr 2024To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare intra- and postoperative outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN), using data from randomised controlled trials (RCTs) or covariate-matched studies (propensity score-matched or matched-pair analysis).
METHODS
A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant literature review was conducted on PubMed, EMBASE, Scopus and CENTRAL for relevant studies comparing off-clamp to on-clamp RAPN. Primary outcomes were estimated blood loss, postoperative percentage decrease in estimated glomerular filtration rate (eGFR), and margin positive rate. Secondary outcomes were operative time, postoperative eGFR, length of stay, all postoperative complications, major complications, and need for transfusion. Random-effects meta-analyses were performed to generate mean differences (MDs) or odds ratios (ORs).
RESULTS
A total of 10 studies (2307 patients) were shortlisted for analysis. There was no significant difference in estimated operative blood loss between off-clamp and on-clamp RAPN (MD 21.9 mL, 95% confidence interval [CI] -0.9 to 44.7 mL; P = 0.06, I = 58%). Off-clamp RAPN yielded a smaller postoperative eGFR deterioration (MD 3.10%, 95% CI 1.05-5.16%; P = 0.008, I = 13%) and lower odds of margin positivity (OR 0.62, 95% CI 0.40-0.94; P = 0.03, I = 0%). No significant differences were found for all secondary outcomes.
CONCLUSIONS
Off-clamp and on-clamp RAPN are similarly effective approaches for selected renal masses. Within the classic trifecta of PN outcomes, off-clamp RAPN yields similar rates of perioperative complications and may possibly offer better preservation of renal function and reduced margin-positive rates.
Topics: Humans; Robotics; Kidney Neoplasms; Nephrectomy; Robotic Surgical Procedures; Glomerular Filtration Rate; Treatment Outcome; Retrospective Studies
PubMed: 38069544
DOI: 10.1111/bju.16250