Robotic Partial Nephrectomy Compared With Open, Laparoscopic Partial Nephrectomy

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A meta-analysis compared outcomes between the use of partial nephrectomy using a robotic surgical approach and open or laparoscopic partial nephrectomy.
A meta-analysis compared outcomes between the use of partial nephrectomy using a robotic surgical approach and open or laparoscopic partial nephrectomy.

Undergoing partial nephrectomy using a robotic surgical approach resulted in outcomes that were mostly superior, or at least as good as, those seen with open or laparoscopic partial nephrectomy, according to the results of a meta-analysis published in the Journal of Urology.1

“Robotic partial nephrectomy has now emerged as a safe, effective, even preferred, partial nephrectomy surgical approach for treatment of small renal masses,” wrote Giovanni E. Cacciamani, MD, of the University of Southern California Institute of Urology, and colleagues.

Although partial nephrectomy is the treatment of choice for clinical T1 tumors, there is no professional consensus about whether or not to use a robotic approach for these tumors, according to the study.

In an attempt to assess clinical efficacy of robotic partial nephrectomy compared with an open or laparoscopic approach, Dr Cacciamani and colleagues conducted a comprehensive literature review and meta-analysis of worldwide English literature on the approach. The analysis included data from 33 studies encompassing 20,282 patients.

“Prior systematic reviews and meta-analyses of [robotic partial nephrectomy] have been somewhat limited in scope,” the researchers wrote. “For example, the most recent [robotic partial nephrectomy] meta-analysis, which evaluated only 19 studies (compared to our 33) of [open partial nephrectomy] vs [robotic partial nephrectomy], concluded that although [robotic partial nephrectomy] had lower comorbidity and better renal function, data about mortality were lacking.[2] For the first time our systematic review assesses survival data, which appear to favor [robotic partial nephrectomy], even if positive margin rates are similar between the 2 approaches.”

When robotic partial nephrectomy to open partial nephrectomy were compared, it was revealed that the robotic approach was superior in multiple categories including blood loss (P < .00001), transfusion (odds ratio [OR] 1.81; P < .001), complications (OR 1.87; P < .00001), hospital stay; P = .001), readmissions (OR 2.58; P = .005), percentage reduction of latest estimated glomerular filtration rate (P = .04), recurrence rate (OR 5.14; P < .00001), and overall mortality (OR 4.45; P < .0001).

The robotic approach was also determined to be superior to laparoscopic partial nephrectomy for ischemia time (P < .0001), conversion rate (OR 2.61; P = .002), intraoperative complications (OR 2.05; P < .00001), postoperative complications (OR 1.27; P = .0003), positive margins (OR 2.01; P < .0001), percentage decrease of latest estimated glomerular filtration rate (P = .02), and overall mortality (OR 2.98; P = .04)

There were similar rates of conversion to radical nephrectomy between the 2 groups. A sensitivity analysis of this comparison showed similar results to that of the pooled cumulative analysis.

The researchers admitted in their discussion of the results that a limitation of the study is the level of evidence available for robotic partial nephrectomy. In fact, no level I prospective randomized data are available, they wrote. The level of evidence for robotic partial nephrectomy, according to categorizations from the Oxford Centre for Evidence-Based Medicine Levels of Evidence Working Group 2011, was level II in 5%, level III in 74%, and level IV in 21% of the publications surveyed.

“Another shortcoming of the study is the relatively short follow-up (approximately 5 years) reported in most series,” the researchers wrote. “Since many recurrences are noted after 5 years, the oncologic data reported here should be viewed with caution.”

References

  1. Cacciamani GE, Medina LG, Gill T, et al. Impact of surgical factors on robotic partial nephrectomy outcomes: comprehensive systematic review and meta-analysis. J Urol. 2018;200(2):258-274.
  2. Xia L, Wang X, Xu T, Guzzo TJ. Systematic review and meta-analysis of comparative studies reporting perioperative outcomes of robot-assisted partial nephrectomy versus open partial nephrectomy. J Endourol. 2017;31(9):893-909.

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