Comparison of robotic and open partial nephrectomy for highly complex renal tumors (RENAL nephrometry score ?10).
ABSTRACT: PURPOSE:To compare the outcomes of robotic partial nephrectomy (RPN) with those of open PN (OPN) in patients with highly complex renal tumors defined as RENAL nephrometry score ? 10. MATERIALS AND METHODS:We analyzed clinical data from a total of 149 patients who underwent OPN or RPN for a highly complex renal mass at our institution between 2003 and 2017. Perioperative data, complication profiles, functional outcomes, pathologic variables, and oncologic outcomes were evaluated in both groups. RESULTS:The median (interquartile range, IQR) patient age was 52.0 (42.0-59.0) years, and the median (IQR) follow-up period was 30.0 (7.0-54.0) months. Among the patients, 64 (43.0%) and 85 (57.0%) underwent OPN and RPN, respectively. The RPN group showed higher rates of clinical T1b and ? T2 than the OPN group (p = 0.019). There were no significant differences between the groups in terms of intraoperative outcomes such as operation time, estimated blood loss, warm ischemic time, and transfusion. Notably, the RPN group showed significantly shorter length of hospital stay than the OPN group (p < 0.001). Regarding the complication profiles and renal functional outcomes, no significant differences were reported between the groups. The estimated glomerular filtration rate decline from baseline at the last follow-up showed no significant differences between the two groups (p = 0.351). Kaplan-Meier survival analysis also showed no significant differences in survival outcomes between the groups (log-rank test, all p > 0.05). CONCLUSIONS:RPN performed in patients with highly complex renal tumors offers perioperative, functional, and oncologic outcomes comparable to those associated with OPN.
Project description:Introduction:Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).Methods:A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review.Results:Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN.Conclusions:Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.
Project description:<h4>Objectives</h4>To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN).<h4>Materials and methods</h4>A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in October 2013. All relevant studies comparing RPN with OPN were included for further screening. A cumulative meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot.<h4>Results</h4>Eight studies were included for the analysis, including a total of 3418 patients (757 patients in the robotic group and 2661 patients in the open group). Although RPN procedures had a longer operative time (weighted mean difference [WMD]: 40.89; 95% confidence interval [CI], 14.39-67.40; p?=?0.002), patients in this group benefited from a lower perioperative complication rate (19.3% for RPN and 29.5% for OPN; odds ratio [OR]: 0.53; 95%CI, 0.42-0.67; p<0.00001), shorter hospital stay (WMD: -2.78; 95%CI, -3.36 to -1.92; p<0.00001), less estimated blood loss(WMD: -106.83; 95%CI, -176.4 to -37.27; p?=?0.003). Transfusions, conversion to radical nephrectomy, ischemia time and estimated GFR change, margin status, and overall cost were comparable between the two techniques. The main limitation of the present meta-analysis is the non-randomization of all included studies.<h4>Conclusions</h4>RPN appears to be an efficient alternative to OPN with the advantages of a lower rate of perioperative complications, shorter length of hospital stay and less blood loss. Nevertheless, high quality prospective randomized studies with longer follow-up period are needed to confirm these findings.
Project description:OBJECTIVES:To investigate perioperative, oncologic, and functional outcomes of robot-assisted radical prostatectomy (RARP) in men of age ? 75 years in comparison with younger men. METHODS:From November 2011 to December 2018, six hundred and thirty patients with prostate cancer underwent robot-assisted radical prostatectomy (RARP). A total of 614 patients were analyzed after excluding 16 patients who were treated with hormone therapy prior to RARP. Patients were divided into 2 groups based on their age (age ? 75 years: N = 46 patients and age < 75 years: N = 568 patients). Perioperative parameters regarding oncologic/functional outcomes and complication status were compared between the 2 groups. Clavien-Dindo classification was used to classify perioperative complications. Clinical and pathological status including stage, positive margin, continence, and potency status after RARP were analyzed. RESULTS:Five-hundred sixty-eight and forty-six men were of age <75 and ? 75 years, respectively. There were no significant differences between the 2 groups in terms of oncologic outcomes (positive resection margin rate and PSA failure). The duration of hospitalization was longer in older patients but was not statistically significant (P = 0.051). A total number of Clavien ?3 complications that occurred within a month after RARP were 15 (2.6%) and 2 (4.3%) in younger men (age < 75 years) and older men (age ? 75 years), respectively (P = 0.359). CONCLUSION:The present study showed that the oncologic and surgical outcomes in the elderly group were similar to those in the younger population. However, the duration of hospitalization seemed to be longer in older patients (age ? 75 years), despite similar complication rates.
Project description:After minimally invasive surgery gained popularity in gynecology, laparoscopic operations became widespread among oncologic operations. However, more studies evaluating experiences of oncologic surgeons during the learning period of laparoscopy are needed. To compare the surgical outcomes and perioperative complications of laparoscopic surgery and laparotomy in the treatment of early-stage endometrioid endometrial cancer patients, we retrospectively investigated patients who underwent surgery due to endometrial cancer at our institution between 2014 and 2018. Early-stage (stage I) endometrioid endometrial cancer patients were included in the study. Operative times, length of hospital stay, extracted pelvic lymph nodes, perioperative complications, and blood loss were compared. A total of 128 patients were treated for stage I endometrial cancer during the study period. Sixty-two patients (48.4%) underwent laparoscopic surgery, and 66 (51.6%) patients underwent laparotomy. Median operation time and pelvic lymph node count in the laparotomy and laparoscopy groups did not demonstrate statistically significant differences. However, the length of hospital stay, estimated blood loss, and perioperative complication rate were lower in the laparoscopic surgery group. Laparoscopic surgery in early-stage endometrial cancer may be performed with less blood loss, shorter duration of hospital stays, and similar lymph node counts compared to laparotomic surgery.
Project description:To evaluate comparative renal functional preservation, perioperative and oncologic outcomes, and complications of thermal ablation (TA) versus partial nephrectomy (PN) in management of Small renal masses (SRMs) in solitary kidney.Medline, Embase, Web of Science and the Cochrane Library were systematically searched. A meta-analysis for comparative studies comparing TA with PN was performed. According to predefined inclusion criteria, seven datasets were identified from 8 observational studies including a total of 628 patients. Cumulated data showed the changes of creatinine (p=0.02) and estimated glomerular filtration rate (eGFR) (p<0.0001) in TA arm were significantly less than these in PN arm. Significantly less new-set chronic kidney disease (CKD) was observed in TA group (p=0.04). In terms of postoperative dialysis rate, the difference favoring TA was also noted, though there is no statistical significance (p=0.09). With regard to perioperative outcomes, our data demonstrated that patients who underwent TA had significantly shorter operation time (p=0.002), less blood loss (p<0.0001), shorter length of stay (p<0.00001), and less transfusion rate (p=0.01) than those underwent PN. In addition, patients underwent TA suffered less intra- and postoperative complications (p=0.007, p<0.00001; respectively). With regard to oncologic outcomes, disease-free survival (DFS) (p<0.00001) and cancer-specific survival (CSS) (p=0.01) in the PN arm were significantly better than these of the TA arm. But, TA yielded a comparable overall survival to PN (p=0.40). Sensitivity analyses led to very similar results with overall results, and confirmed its stability.Our analysis indicates that PN have advantage in controlling cancer recurrence. However, TA is associated with significantly better renal functional preservation and perioperative outcomes, and less complications without increasing overall death. Our data suggest that indication for TA may be extended to select younger, healthier patients who desire a much less invasive therapeutic option.
Project description:Background:Perioperative inflammation is associated with poor oncologic outcomes. Regional analgesia has been shown mitigate some of these inflammatory changes and be associated with better oncologic outcomes in patients with hepatic malignancies. The mechanism for this effect, however, remains unclear. The authors sought to compare systemic biomarker concentrations in a comprehensive and oncologically relevant panel in the perioperative setting between patients undergoing thoracic epidural analgesia (TEA) and intra-venous patient- controlled analgesia (IV-PCA) for resection of hepatic metastatic disease. Results:Clinicopathologic variables and baseline biomarkers were similar between TEA (n = 46) and IV-PCA (n = 16) groups. Of the biomarkers which were significantly changed from baseline, there was a lower fold change from baseline in the TEA patients compared to IV-PCA including IL-6 (13.5vs19.1), MCP-1 (1.9vs3.0), IL-8 (2.4vs3.0), and Pentraxin-3 (10.8vs15.6). Overall decreased systemic concentrations of TGFb signaling were noted in TEA patients on POD1 TGFb3 (243.2 vs. 86.0, p = 0.005), POD3 TGFb1 (6558.0 vs. 2063.3, p = 0.004), POD3 TGFb2 (468.3 vs. 368.9, p = 0.036), POD3 TGFb3 (132.2 vs. 77.8, p = 0.028), and POD5 TGFb3 (306.5 vs. 92.2, p = 0.032). POD1 IL-12p70 concentrations were significantly higher in TEA patients (8.3 vs. 1.6, p = 0.024). Conclusion:Epidural analgesia damped the postoperative inflammatory response and systemic immunosuppressive signaling, as well as promoted Th1 systemic signaling early in the post-operative period after hepatic resection for metastatic disease. These differences elaborate on known mechanisms for improved oncologic outcomes with regional anesthesia, and may be considered for biomarker monitoring of effective regional anesthesia in oncologic surgery. Materials and Methods:Patient data, including clinicopathologic variables were collected for this study from the database of a randomized controlled trial comparing perioperative outcomes in patients undergoing hepatic resection with TEA vs. IV-PCA. Patients undergoing resection for metastatic disease were selected for this study. Plasma concentrations (pg/mL) of well-studied biomarkers (IL-1b/2/4/5/6/7/8/10/12p70/13/17, MCP-1 IFN?, TNF?, MIP-1b, GM-CSF, G-CSF, VEGF, Resistin, TGFb1, TGFb2, and TGFb3), as well as novel perioperative markers (CXCL12, CXCL10, Omentin-1, sLeptin R, Vaspin, Pentraxin-3, Galactin-3, FGF-23, PON-1, FGF-21) were measured preoperatively, and on postoperative day (POD)1, POD3, and POD5 using multiplex bead assays. Clinicopathologic variables and perioperative variations in these biomarkers were compared between TEA vs IV-PCA groups.
Project description:Purpose:To summarize and analyze the current evidence about surgical, oncological, and functional outcomes between laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN). Materials and Methods:Through a systematical search of multiple scientific databases in March 2020, we performed a systematic review and cumulative meta-analysis. Meanwhile, we assessed the quality of the relevant evidence according to the framework in the Cochrane Handbook for Systematic Reviews of Interventions. Results:A total of 26 studies with 8095 patients were included. There was no statistical difference between the LPN and OPN in the terms of operation time (p=0.13), intraoperative complications (p=0.94), recurrence (p=0.56), cancer-specific survival (p=0.72), disease-free survival (p=0.72), and variations of estimated glomerular filtration rate (p=0.31). The LPN group had significantly less estimated blood loss (P<0.00001), lower blood transfusion (p=0.04), shorter length of hospital stay (p<0.00001), lower total (p=0.03) and postoperative complications (p=0.02), higher positive surgical margin (p=0.005), higher overall survival (p<0.00001), and less increased serum creatinine (p=0.002). The subgroup analysis showed that no clinically meaningful differences were found for T1a tumors in terms of operation time (p=0.11) and positive surgical margin (p=0.23). In addition, the subgroup analysis also suggested that less estimated blood loss (p<0.0001) and shorter length of hospital stay (p<0.00001) were associated with the LPN group for T1a tumors. Conclusions:This meta-analysis revealed that the LPN is a feasible and safe alternative to the OPN with comparable surgical, oncologic, and functional outcomes. However, the results should be applied prudently in the clinic because of the low quality of evidence. Further quality studies are needed to evaluate the effectiveness LPN and its postoperative quality of life compared with OPN.
Project description:BACKGROUND:The oncologic safety of allogeneic blood transfusion in ovarian cancer patients is unknow. We sought to determine the prevalence and oncologic safety of perioperative allogeneic blood transfusion during interval cytoreduction surgery among women receiving neoadjuvant chemotherapy for ovarian cancer. METHODS:We utilized retrospective chart review to identify a cohort of patients undergoing interval cytoreduction at a large academic tertiary referral center. We compared outcomes in patients who were exposed to perioperative blood transfusion compared with patients who were not exposed. Our primary endpoint was progression free survival; our secondary endpoint was overall survival. Baseline clinical characteristics were collected for patients in each group. RESULTS:Sixty-six women were included in the final cohort of women undergoing interval cytoreductive surgery after NACT. A total of 51 women (77%) were exposed to allogeneic perioperative pRBC transfusion. Fifteen women (23%) were not exposed to transfusion. The baseline characteristics were generally well matched. Women who were not exposed to a perioperative blood transfusion were more likely to have a normalized CA125 prior to undergoing cytoreductive surgery. Preoperative hemoglobin concentration was lower in the transfusion group (10.5 g/dLvs 11.5 g/dL, p <?0.009). Perioperative transfusion was not associated with a significant difference in progression free survival (PFS?=?7.6 months for transfused, 9.4 months for not transfused; log-rank test p =?0.4617). Similarly, there was no observed difference between groups for overall survival (OS?=?23.6 months for transfused, 22.5 months for not transfused; log-rank test p =?0.1723). CONCLUSIONS:Women undergoing neoadjuvant chemotherapy for ovarian cancer are at high risk of exposure to blood transfusion at the time of interval cytoreductive surgery. Future studies will continue to evaluate the safety and impact of transfusion on ovarian cancer survival in this at risk population.
Project description:Cardiopulmonary bypass (CPB) surgery initiates a systemic inflammatory response, which is associated with postoperative morbidity and mortality. Hemoadsorption (HA) of cytokines may suppress inflammatory responses and improve outcomes. We tested a new sorbent used for HA (CytoSorb™; CytoSorbents Europe GmbH, Berlin, Germany) installed in the CPB circuit on changes of pro- and anti-inflammatory cytokines levels, inflammation markers, and differences in patients' perioperative course.In this first pilot trial, 37 blinded patients were undergoing elective CPB surgery at the Medical University of Vienna and were randomly assigned to HA (n = 19) or control group (n = 18). The primary outcome was differences of cytokine levels (IL-1?, IL-6, IL-18, TNF-?, and IL-10) within the first five postoperative days. We also analyzed whether we can observe any differences in ex vivo lipopolysaccharide (LPS)-induced TNF-? production, a reduction of high-mobility box group 1 (HMGB1), or other inflammatory markers. Additionally, measurements for fluid components, blood products, catecholamine treatment, bioelectrical impedance analysis (BIA), and 30-day mortality were analyzed.We did not find differences in our primary outcome immediately following the HA treatment, although we observed differences for IL-10 24 hours after CPB (HA: median 0.3, interquartile range (IQR) 0-4.5; control: not traceable, P = 0.0347) and 48 hours after CPB (median 0, IQR 0-1.2 versus not traceable, P = 0.0185). We did not find any differences for IL-6 between both groups, and other cytokines were rarely expressed. We found differences in pretreatment levels of HMGB1 (HA: median 0, IQR 0-28.1; control: median 48.6, IQR 12.7-597.3, P = 0.02083) but no significant changes to post-treatment levels. No differences in inflammatory markers, fluid administration, blood substitution, catecholamines, BIA, or 30-day mortality were found.We did not find any reduction of the pro-inflammatory response in our patients and therefore no changes in their perioperative course. However, IL-10 showed a longer-lasting anti-inflammatory effect. The clinical impact of prolonged IL-10 needs further evaluation. We also observed strong inter-individual differences in cytokine levels; therefore, patients with an exaggerated inflammatory response to CPB need to be identified. The implementation of HA during CPB was feasible.ClinicalTrials.gov: NCT01879176, registration date: June 7, 2013.
Project description:BACKGROUND:Hospital-level measures of patient satisfaction and quality are now reported publically by the Centers for Medicare and Medicaid Services. There are limited metrics specific to cancer patients. We examined whether publically reported hospital satisfaction and quality data were associated with surgical oncologic outcomes. METHODS:The Nationwide Inpatient Sample was utilized to identify patients with solid tumors who underwent surgical resection in 2009 and 2010. The hospitals were linked to Hospital Compare, which collects data on patient satisfaction, perioperative quality, and 30-day mortality for medical conditions (pneumonia, myocardial infarction [MI], and congestive heart failure [CHF]). The risk-adjusted hospital-level rates of morbidity and mortality were calculated for each hospital and the means compared between the highest and lowest performing hospital quartiles and reported as absolute reduction in risk (ARR), the difference in risk of the outcome between the two groups. All statistical tests were two-sided. RESULTS:A total of 63197 patients treated at 448 hospitals were identified. For patients at high vs low performing hospitals based on Hospital Consumer Assessment of Healthcare Providers and Systems scores, the ARR in perioperative morbidity was 3.1% (95% confidence interval [CI] = 0.4% to 5.7%, P = .02). Similarly, the ARR for mortality based on the same measure was -0.4% (95% CI = -1.5% to 0.6%, P = .40). High performance on perioperative quality measures resulted in an ARR of 0% to 2.2% for perioperative morbidity (P > .05 for all). Similarly, there was no statistically significant association between hospital-level mortality rates for MI (ARR = 0.7%, 95% CI = -1.0% to 2.5%), heart failure (ARR = 1.0%, 95% CI = -0.6% to 2.7%), or pneumonia (ARR = 1.6%, 95% CI = -0.3% to 3.5%) and complications for oncologic surgery patients. CONCLUSION:Currently available measures of patient satisfaction and quality are poor predictors of outcomes for cancer patients undergoing surgery. Specific metrics for long-term oncologic outcomes and quality are needed.