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Background: Deterioration of renal function is associated with increased all-cause mortality. In renal masses larger than 4 cm, whether partial versus radical nephrectomy (PN vs. RN) might affect long-term functional outcomes is unknown. This study tested the association between PN versus RN and postoperative acute kidney injury (AKI), recovery of at least 90% of the preoperative estimated glomerular filtration rate (eGFR) at 1 year, upstaging of chronic kidney disease (CKD) one stage or more at 1 year, and eGFR decline of 45 ml/min/1.73 m 2 or less at 1 year., Methods: Data from 23 high-volume institutions were used. The study included only surgically treated patients with single, unilateral, localized, clinical T1b-2 renal masses. Multivariable logistic regression analyses were performed., Results: Overall, 968 PN patients and 325 RN patients were identified. The rate of AKI was lower in the PN versus the RN patients (17% vs. 58%; p < 0.001). At 1 year after surgery, for the PN versus the RN patients, the rate for recovery of at least 90% of baseline eGFR was 51% versus 16%, the rate of CKD progression of ≥ 1 stage was 38% versus 65%, and the rate of eGFR decline of 45 ml/min/1.73 m 2 or less was 10% versus 23% (all p < 0.001). Radical nephrectomy independently predicted AKI (odds ratio [OR], 7.61), 1-year ≥ 90% eGFR recovery (OR, 0.30), 1-year CKD upstaging (OR, 1.78), and 1-year eGFR decline of 45 ml/min/1.73 m 2 or less (OR, 2.36) (all p ≤ 0.002)., Conclusions: For cT1b-2 masses, RN portends worse immediate and 1-year functional outcomes. When technically feasible and oncologically safe, efforts should be made to spare the kidney in case of large renal masses to avoid the hazard of glomerular function loss-related mortality., (© 2024. Society of Surgical Oncology.)

Background: Ischemia time during partial nephrectomy (PN) is among the greatest determinants of acute kidney injury (AKI). Whether this association is affected by the preoperative risk of AKI has never been investigated., Objective: To assess the effect of the interaction between the preoperative risk of AKI and ischemia time on the probability of AKI during PN., Design, Setting, and Participants: Data of 944 patients treated with on-clamp PN for cT1 renal tumors were extracted from the Registry of Conservative and Radical Surgery for Cortical Renal Tumor Disease (RECORD2) database, a prospective multicenter project., Outcome Measurements and Statistical Analysis: We estimated the preoperative risk of AKI (defined according to the risk/injury/failure/loss/end-stage [RIFLE] criteria) according to age, baseline renal function, clinical stage, preoperative aspects and dimensions used for an anatomical (PADUA) score, and surgical approach. Classification and regression tree (CART) analysis identified patients at "high" and "low" risk of AKI. Finally, we plotted the probability of AKI over ischemia time stratified by the preoperative risk of AKI., Results and Limitations: Overall, 235 (25%) patients experienced AKI after surgery. At multivariable analysis, older patients, those with more complex tumors, those with higher baseline function, and those treated with open surgery had an increased risk of AKI (all p ≤ 0.011). According to the first split at CART analysis, patients were categorized as those with "high" and "low" risk of AKI having a probability of >40% or <40%. For low-risk patients, the probability of AKI in case of <10 versus >20 min of ischemia was 13% versus 28% (absolute risk increase 15%). The risk of AKI for high-risk patients who had <10 versus >20 min of ischemia was 31% versus 77%. This corresponds to an absolute risk increase of 45%. Limitations include retrospective data analyses and lack of surgeons' prior experience., Conclusions: Ischemia time during PN has different implications for patients with different health status. Clamp time seems less clinically relevant for patients in good conditions who may endure prolonged ischemia with a mild increase in the risk of AKI, whereas frail patients seem to be more vulnerable to ischemic damage even for short clamp time. For individualized intra- and postoperative management, duration of ischemia needs to be questioned in the context of the individual health status., Patient Summary: Functional sequelae related to ischemia time during partial nephrectomy depend on baseline health status. The correlation between the duration of ischemia and baseline health status should be taken into account toward individualized intra- and postoperative management., (Copyright © 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

We hypothesized that pT3a stage at nephrectomy can be accurately predicted in cT1N0M0 clear cell-renal cell carcinoma (cc-RCC) patients. Of 236 patients, treated with either partial or radical nephrectomy (2005-2019), 25 (10.6%) harbored pT3a stage. Multivariable logistic regression models predicting pT3a were fitted using age, tumor size, tumor location and exophytic rate. The new model was 81% accurate. In calibration plots, minimal departures from ideal prediction were recorded. In decision curve analyses, a net-benefit throughout all threshold probabilities was recorded relative to the treat-all or treat-none strategies. Using a probability cut-off of 21% for presence of pT3a stage, 38 patients (16.1%) were identified, in whom pT3a rate was 36.8%. Conversely, in 198 patients (83.9%) below that cut-off, the rate of pT3a was 5.6%. Alternative user-defined cut-offs may be selected. The new model more accurately identifies a subgroup of cT1N0M0 cc-RCC patients with substantially higher risk of pT3a stage than average., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Partial nephrectomy (PN) has a non-negligible perioperative morbidity. Comparative evidence of the available surgical techniques is limited., Objective: To compare the perioperative outcomes of open, laparoscopic, and robotic PN., Methods: Data of 2331 patients treated with PN for cT1 renal tumors were extracted from the RECORd2 database, a prospective multicenter project. Multivariable regression models assessed the relationship between surgical technique and surgical margins, warm ischemia time, postoperative complications, and acute kidney injury (AKI). The probability of achieving a modified trifecta (negative margins, warm ischemia time <25min, and no Clavien-Dindo ≥2 complications) was examined for each surgical approach., Results: Minimally invasive techniques had lower rate of Clavien-Dindo ≥2 complications than that of open surgery (odds ratio [OR] for robotic surgery: 0.27; 95% confidence interval [95% CI]: 0.15-0.47, p< 0.0001; OR for laparoscopy: 0.52; 95% CI: 0.34-0.78; p= 0.002). The probability of receiving ischemia was highest for robotic PN (p< 0.001). Among on-clamp PN, laparoscopy had longer ischemia than open (estimate: 1.09; 95% CI: -0.00 to 2.18; p= 0.050) and robotic (estimate: 1.36; 95% CI: 0.31-2.40; p= 0.011) surgery. When compared with open PN, the risk of AKI was roughly halved for patients treated by robotic and laparoscopic surgery (both p< 0.0001). Positive margins rate did not differ between the groups (all p≥ 0.1). The likelihood to achieve a modified trifecta was not affected by surgical technique in the overall population (all p≥ 0.075). In Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score < 10 lesions, robotic surgery had higher probability of achieving a modified trifecta than open PN (OR: 1.66; 95% CI: 1.09-2.53; p= 0.018) and laparoscopy (OR: 1.34; 95% CI: 0.94-1.90; p= 0.11)., Conclusions: In PADUA<10 renal tumors, robotic PN allows for higher rates of trifecta than open and laparoscopic surgeries. The impact of surgical technique on perioperative outcomes of PN might be limited in more complex lesions., Patient Summary: We evaluated the association between surgical technique and perioperative outcomes of partial nephrectomy. In less complex (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score < 10) lesions, robotic PN allows for higher rates of trifecta when compared with other surgical techniques., (Copyright © 2019. Published by Elsevier B.V.)

Background: The relationship between acute kidney injury (AKI) and long-term renal function is controversial. The influence of AKI duration on functional recovery after partial nephrectomy has never been investigated., Objective: To investigate the association between AKI and renal function 1yr after partial nephrectomy, and whether this relationship is affected by the duration of AKI., Design, Setting, and Participants: We analyzed the data of 1893 patients treated by partial nephrectomy for a single cT1 N0 M0 renal mass., Outcome Measurements and Statistical Analysis: We defined three outcomes of interest: (1) recovery of at least 90% of baseline function 1yr after partial nephrectomy, (2) percentage change of 1-yr renal function compared with baseline function, and (3) chronic kidney disease (CKD) upstaging. AKI was defined according to the RIFLE criteria and recorded up to the 7th postoperative day. The association between AKI and each endpoint of interest was examined using regression models after adjustment for common predictors of renal function., Results and Limitations: A total of 388 (20%) patients experienced AKI after surgery. The rate of patients recovering 90% of baseline function was lower in the AKI group (30% vs 61%), while the proportion of patients who had CKD upstaging was significantly higher (51% vs 23%; both p<0.0001). At multivariable analysis, AKI was associated with worse renal function 1yr after partial nephrectomy, regardless of the outcome of interest (all p<0.0001). Longer AKI increases the risk of functional deterioration, especially after the 3rd day of injury. The risk of CKD upstaging for an average patient who had 1-3 versus ≥4 d of AKI was 46% (95% confidence interval [CI]: 40%, 52%) versus 67% (95% CI: 55%, 78%; absolute risk increase of 21%; 95% CI: 8%, 34%)., Conclusions: AKI negatively affects long-term functional recovery after partial nephrectomy, and thus, modifiable factors associated with AKI should be identified and corrected preoperatively. The duration of injury is informative, and should be included in the assessment of AKI and in future studies addressing this topic., Patient Summary: Proper functional recovery after partial nephrectomy is jeopardized by acute kidney injury (AKI). Inclusion of the dimension of time into classification systems for AKI may be beneficial for postoperative risk stratification., (Copyright © 2019 European Association of Urology. All rights reserved.)

Background: In patients treated with partial nephrectomy, prior evidence showed that peri-operative outcomes, such as complications and ischemia time, improved as a function of the surgical experience of the surgeon, but data on functional outcomes after surgery are still scarce. Methods: We retrospectively analyzed data of 4011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. The operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery. Results: A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 37 (31%) and 55 (46%) surgeons contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to the learning curves of both approaches. In the laparoscopic group, 8% and 55% of patients developed AKI and recovered at least 90% of their baseline eGFR, respectively. After adjusting for confounders, we did not find evidence of an association between surgical experience and AKI after laparoscopic partial nephrectomy (odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p = 0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95% CI: 0.9988, 1.0005; p = 0.5). Among patients who underwent robot-assisted partial nephrectomy, AKI occurred in 11% of patients, whereas 54% recovered at least 90% of their baseline eGFR. On multivariable analyses, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95% CI: 0.9992, 1.0037; p = 0.2), with similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95% CI: 0.9980, 1.0022; p = 0.9). Virtually the same findings were found on sensitivity analyses. Conclusions: In patients treated with laparoscopic or robot-assisted partial nephrectomy, our data suggest that the surgical experience of the operating surgeon might not be a key determinant of functional recovery after surgery. This raises questions about the use of serum markers to assess functional recovery in patients with two kidneys and opens the discussion on what are the key steps of the procedure that allowed surgeons to achieve optimal outcomes since their initial cases. [ABSTRACT FROM AUTHOR]

Purpose: In the emerging field of robotics, only few studies investigated the transition between different robotic platforms in terms of surgical outcomes. We aimed at assessing surgical outcomes of patients receiving robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN) at a high-volume robotic center during the transition from Si to Xi Da Vinci surgical systems. Methods: We analyzed data of 1884 patients undergoing RARP (n = 1437, 76%) and RAPN (n = 447, 24%) at OLV hospital (Aalst, Belgium) between 2011 and 2021. For both procedures, we assessed operative time, estimated blood loss, length of stay, and positive surgical margins. For RARP, we investigated length of catheterization and PSA persistence after surgery, whereas warm ischemia time, clampless surgery, and acute kidney injury (AKI) were assessed for RAPN. Multivariable analyses (MVA) investigated the association between robotic platform (Si vs. Xi) and surgical outcomes after adjustment for patient- and tumor-related factors. Results: A total of 975 (68%) and 462 (32%) patients underwent RARP performed with the Si vs. Xi surgical system, respectively. Baseline characteristics did not differ between the groups. On MVA, we did not find evidence of a difference between the groups with respect to operative time (estimate: 1.07) or estimated blood loss (estimate: 32.39; both p > 0.05). Median (interquartile range [IQR]) length of stay was 6 (3, 6) and 4 (3, 5) days in the Si vs. Xi group, respectively (p < 0.0001). On MVA, men treated with the Xi vs. Si robot had lower odds of PSM (Odds ratio [OR]: 0.58; p = 0.014). A total of 184 (41%) and 263 (59%) patients received RAPN with the Si and Xi robotic system, respectively. Baseline characteristics, including demographics, functional data, and tumor-related features did not differ between the groups. On MVA, operative time was longer in the Xi vs. Si group (estimate: 30.54; p = 0.006). Patients treated with the Xi vs. Si system had higher probability of undergoing a clampless procedure (OR: 2.56; p = 0.001), whereas the risk of AKI did not differ between the groups (OR: 1.25; p = 0.4). On MVA, patients operated with the Xi robot had shorter length of stay as compared to the Si group (estimate: − 0.86; p = 0.003), whereas we did not find evidence of an association between robotic system and PSM (OR: 1.55; p = 0.3). Conclusion: We found that the Xi robot allowed for improvements in peri-operative outcomes as compared to the Si platform, with lower rate of positive margins for RARP and higher rate of off-clamp procedures for RAPN. Hospital stay was also shorter for patients operated with the Xi vs. Si robot, especially after robot-assisted partial nephrectomy. Awaiting future investigations—in particular, cost analyses—these results have important implications for patients, surgeons, and healthcare policymakers. [ABSTRACT FROM AUTHOR]

Background: In robot-assisted partial nephrectomy (RAPN) renorrhaphy is used to achieve hemostatic control of the tumoral resection bed, with detrimental impact on renal function. Hemostatic agents are used to achieve rapid and optimal hemostasis. GATT-Patch is a new hemostatic sealant that has already demonstrated promising results. Objective: Compare GATT-Patch and standard renorrhaphy in terms of hemostatic capacity, ischemia time, and prevention of urinary leakage after RAPN in a porcine model. Design, Setting, and Participants: In this preclinical randomized controlled trial, four pigs underwent 32 RAPNs. After resection, GATT-Patch application and performance of classic renorrhaphy were randomized. After the procedure, the resection bed was reinspected. A necropsy study evaluated the adhesiveness of the patch, and retrograde pyelography was performed to determine the leakage burst pressure. Intervention: Application of GATT-Patch and performance of classic renorrhaphy were randomized and surgeons blinded to the hemostatic technique to be performed. Outcome Measurements and Statistical Analysis: Warm ischemia, hemostatic control, active bleeding during hemostatic control, total procedure time, bleeding at reinspection, and presence of urinary leakage on retrograde pyelography were recorded. Continuous variables were compared using the Student t-test. Categorical variables were compared using the Chi-square or Fisher's exact test. Results and Limitations: GATT-Patch reduced warm ischemia time (WIT), time to achieve hemostatic control, active bleeding time, and total procedure time, achieving hemostasis in 100% of the cases. Rebleeding at reinspection occurred in 0% of the GATT-Patch group. Renal parenchyma damage was observed in 100% of renorrhaphy cases and in 0% of GATT-Patch cases. Conclusions: GATT-Patch guaranteed optimal hemostasis and urine sealant effect after RAPN in porcine models. Compared to renorrhaphy, we observed a reduction in WIT, total procedure time, and potential reduction in healthy parenchyma loss. Patient Summary: GATT-Patch stops bleeding and provides hemostasis faster than suturing after resection of portions of the kidney in pigs. It might be tested in patients undergoing partial nephrectomy for kidney cancer. [ABSTRACT FROM AUTHOR]

To examine the effect of frailty on short-term post-operative outcomes and total hospital charges (THCs) in patients with non-metastatic renal cell carcinoma, treated with partial nephrectomy (PN). Within the National Inpatient Sample (NIS) database we identified 25,545 patients treated with PN from 2000 to 2015. We used the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining indicator and we examined the rates of frailty over time, as well as its effect on overall complications, major complications, blood transfusions, non-home-based discharge, length of stay (LOS) and THCs. Time trends and multivariable logistic, Poisson and linear regression models were applied. Overall, 3574 (14.0%) patients were frail, 2677 (10.5%) were older than 75 years and 2888 (11.3%) had Charlson comorbidity index (CCI) ≥ 2. However, the vast majority of frail patients were neither elderly nor comorbid (83%). Rates of frail patients treated with PN increased over time, from 8.3 in 2000 to 18.1% in 2015 (all p < 0.001). Frail patients showed higher rates of overall complications (43.5 vs. 30.3%), major complications (16.6 vs. 9.8%), blood transfusions (11.6 vs 8.3%) and non-home-based discharge (9.9 vs. 5.4%). longer LOS [4 (IQR: 3–6) vs. 4 (IQR: 2–5) days] and higher THCs ($43,906 vs. $38,447 – all p < 0.001). Moreover, frailty status independently predicted overall complications (OR: 1.73), major complications (OR: 1.63), longer LOS (RR: 1.07) and higher THCs (RR: +$7506). Finally, a dose-response on the risk of suboptimal surgical outcomes was shown in patients with multiple risk factors. One out of seven patients is frail at time of surgery and this rate is on the rise. Moreover, frailty is associated with adverse outcomes after PN. In consequence, preoperative assessment of frailty status should be implemented, to identify patients who may benefit from pre- or postoperative measures aimed at improving surgical outcomes in this patient population. [ABSTRACT FROM AUTHOR]

In a cohort of 2584 patients treated at 26 referral centers, Antonelli I et al i . found that the model performs well in patients treated with laparoscopic or robotic surgery, whereas the performances were worse in case of open surgery. The oncological outcomes after partial nephrectomy (PN) are not the sole endpoint and, on this matter, the functional outcomes have been the focus of many research articles over time.1,2 In fact, poor functional outcomes after renal surgery, in terms of reduced estimated glomerular filtration rate (eGFR), can determine chronic kidney disease (CKD), cardiovascular events, and ultimately decrease survival.3 While CKD was first described as a syndrome in the 19th century, the acute cessation of renal function (today often referred to as acute kidney injury [AKI]) was recognized during World War II in individuals with crash injuries during the London Blitz.4 Today, we know that AKI and CKD are "interconnected syndromes", and that many factors are associated with their occurrence4,5 (Fig. Predicting acute kidney injury after robot-assisted partial nephrectomy: implications for patient selection and postoperative management. [Extracted from the article]

Editorial Comment from Dr Martini et al. to Independent external validation of a nomogram to define risk categories for a significant decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy Independent external validation of a nomogram to define risk categories for a significant decline in estimated glomerular filtration rate after robotic-assisted partial nephrectomy. Defining risk categories for a significant decline in estimated glomerular filtration rate after robotic partial nephrectomy: implications for patient follow-up. [Extracted from the article]

We propose a new three-dimensional (3D) perfusion zone algorithm to plan selective clamping during partial nephrectomies. The study shows that the algorithm is sufficiently accurate in 92% of the cases. Multicentric validation should assess its value compared with 3D models only. Selective clamping during robot-assisted partial nephrectomy (RAPN) requires extensive knowledge on patient-specific renal vasculature, obtained through imaging. To validate an in-house developed perfusion zone algorithm that provides patient-specific three-dimensional (3D) renal perfusion information. Between October 2020 and June 2022, 25 patients undergoing RAPN at Ghent University Hospital were included. Three-dimensional models, based on preoperative computed tomography (CT) scans, showed the clamped artery's ischemic zone, as calculated by the algorithm. All patients underwent selective clamping during RAPN. Indocyanine green (ICG) was administered to visualize the true ischemic zone perioperatively. Surgery was recorded for a postoperative analysis. The true ischemic zone of the clamped artery was compared with the ischemic zone predicted by the algorithm through two metrics: (1) total ischemic zone overlap and (2) tumor ischemic zone overlap. Six urologists assessed metric 1; metric 2 was assessed objectively by the authors. In 92% of the cases, the algorithm was sufficiently accurate to plan a selective clamping strategy. Metric 1 showed an average score of 4.28 out of 5. Metric 2 showed an average score of 4.14 out of 5. A first limitation is that ICG can be evaluated only at the kidney surface. A second limitation is that mainly patients with impaired renal function are expected to benefit from this technology, but contrast-enhanced CT is required at present. The proposed new tool demonstrated high accuracy when planning selective clamping for RAPN. A follow-up prospective study is needed to determine the tool's clinical added value. In partial nephrectomy, the surgeon has no information on which specific arterial branches perfuse the kidney tumor. We developed a surgeon support system that visualizes the perfusion zones of all arteries on a three-dimensional model and indicates the correct arteries to clamp. In this study, we validate this tool. [ABSTRACT FROM AUTHOR]