Background

Robot-assisted partial nephrectomy (RAPN) represents a widely accepted minimally invasive alternative to open and laparoscopic surgery for the treatment of clinically localized renal tumors.

Objective

To assess the feasibility of RAPN in a contemporary series of patients with highly complex tumors (PADUA score ≥10) treated at four high-volume robotic surgery institutions.

Design, setting, and participants

Data from a prospectively maintained multi-institutional database on patients subjected to RAPN between 2010 and 2017 were reviewed. For the scope of this analysis, only patients with highly complex renal tumors, defined as a PADUA score between 10 and 14, were included.

Surgical procedure

RAPN was performed with the da Vinci Si or Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) using novel technologies such as TilePro and near-infrared fluorescence imaging.

Measurements

Intraoperative, postoperative, surgical, and oncological outcomes were collected. Predictors of optimal surgical outcomes defined according to the Margin Ischemia and Complications binary system (absence of Clavien-Dindo >2 complications, warm ischemia time [WIT] <20 min, and absence of positive surgical margins) were determined using logistic regression models (LRMs).

Results and limitations

Overall, 255 patients with complex renal tumors were included. The mean operative time was 165 min and mean WIT was 18.6 min. Overall, WIT was longer than 20 min in 86 (33.7%) individuals, while a Clavien-Dindo >2 complication and positive surgical margins were observed in 13 (5.1%) and four (out of 211 patients with malignant histotypes; 1.9%) individuals, respectively. Optimal surgical outcomes were achieved in 158 (62.0%) patients. At a median follow-up of 28 mo, one (0.4%) local and two (0.8%) distant recurrences of the disease were observed. In multivariable LRMs, extremely complex tumors (PADUA score 12–13) were associated with an increased likelihood of not achieving optimal outcomes (odds ratio: 2.31; p = 0.024). Besides tumor complexity, male gender was also associated with a two-fold higher risk of not achieving optimal surgical outcomes (p = 0.029).

Conclusions

In experienced hands, RAPN can be considered as an effective treatment option even in cases of complex renal lesions. However, increasing tumor complexity may affect the surgical outcomes in this highly selected patient population.

Patient summary

We reported our multicentric experience with robot-assisted partial nephrectomy (RAPN) in patients with complex renal tumors. We demonstrated that, in experienced hands, RAPN is a feasible and safe treatment option even in such patients. Novel technologies applied to RAPN may further extend the indications without compromising the outcomes.

中文翻译：

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机器人辅助部分肾切除术治疗复杂性（PADUA评分≥10）肿瘤：来自四个高容量中心的多中心经验的技术和结果。

背景

机器人辅助部分肾切除术（RAPN）代表了开放式和腹腔镜手术的微创替代方案，用于治疗临床局部性肾脏肿瘤。

客观的

评估RAPN在由四个大型机器人手术机构治疗的一系列高度复杂肿瘤（PADUA评分≥10）的当代患者中的可行性。

设计，设置和参与者

回顾了前瞻性维护的多机构数据库中2010年至2017年接受RAPN的患者的数据。在本分析的范围内，仅包括高度复杂的肾脏肿瘤患者（定义为PADUA评分在10到14之间）。

手术程序

RAPN使用达芬奇Si或Xi手术系统（Intuitive Surgical，美国加利福尼亚州桑尼维尔）使用诸如TilePro和近红外荧光成像等新技术进行。

测量

收集术中，术后，手术和肿瘤学结果。使用Logistic回归模型（LRM）确定根据边缘缺血和并发症二元系统（没有Clavien-Dindo> 2并发症，温暖缺血时间[WIT] <20分钟，并且没有阳性切缘）定义的最佳手术结局的预测指标）。

结果与局限性

总体而言，纳入了255例患有复杂肾肿瘤的患者。平均手术时间为165分钟，平均WIT为18.6分钟。总体而言，在86位（33.7％）的患者中，WIT超过20分钟，而在13位（5.1％）和4位（211位恶性组织型患者中，有1.9位）出现Clavien-Dindo> 2并发症并观察到手术切缘阳性。个人。158名（62.0％）患者达到了最佳手术效果。在28个月的中位随访中，观察到该病1例（0.4％）局部复发和2例（0.8％）远处复发。在多变量LRM中，极度复杂的肿瘤（PADUA评分12-13）与未达到最佳预后的可能性增加相关（比值比：2.31；p = 0.024）。除了肿瘤的复杂性之外，男性也可能导致无法获得最佳手术结果的风险增加了两倍（p  = 0.029）。

结论

在有经验的手中，即使在复杂的肾脏病变的情况下，RAPN也可以被视为有效的治疗选择。但是，增加的肿瘤复杂性可能会影响这一高度选择的患者人群的手术结果。

病人总结

我们报告了在复杂肾脏肿瘤患者中使用机器人辅助部分肾切除术（RAPN）的多中心经验。我们证明，在有经验的人手中，即使在此类患者中，RAPN也是一种可行且安全的治疗选择。应用于RAPN的新技术可能会进一步扩展适应症，而不会影响结果。