Comparison of Intra- and Post- Operative Outcomes of Straight Laparoscopic, Hand-Assisted Laparoscopic, and Robotic-Assisted Laparoscopic Partial Nephrectomies for Small Renal Masses at a Single Institution
Michel Apoj, B.S, Liz Wang, MD, Wason Shaun, MD, Mark Katz, MD, David Wang, MD.
Boston University School of Medicine, Boston, MA
BACKGROUND: Partial nephrectomy has become the standard operative procedure for the treatment of small renal masses. Due to a decrease in morbidity with similar long-term outcomes, the minimally invasive compared to open approach has become the preferred surgical technique. This surgery can be performed via Straight Laparoscopy (SL), Hand-Assisted laparoscopy (HA), or Robotic-Assisted laparoscopy (RA). The purpose of this study was to compare the intra- and post-operative outcomes of these techniques at a single-institution.
METHODS: A single-institution retrospectively review of intra- and post-operative outcomes in minimally invasive partial nephrectomy cases between 2012 and 2018 was performed. Statistical analysis included a linear regression model adjusting for age, gender, demographics, size of tumor on pathology, and RENAL nephrometry score to investigate differences in estimated blood loss (EBL), operative time (OT), length of stay (LOS), and warm ischemia time (WI). We used a chi square analysis to investigate differences in post-operative complications (up to 30 days), demographics, and gender, and analysis of variances (ANOVA) to check for differences in positive margin rate, RENAL nephrometry scores, and age among the three different surgical techniques.
RESULTS: A total of 164 cases were reviewed. 36, 65, and 63 surgeries were performed using the SL, HA, and RA technique, respectively. In our study, the SL technique was more popular in the early years (67% between 2011 - 2013) and RA in the later years (92% between 2014 - 2018, and 48% between 2017 - 2018). There were no differences among the cohorts in regards to age, gender, intra-operative complications, and positive margin rates (p >0.05). The HA technique had a higher RENAL nephrometry score (mean of 1.38) compared to RA and SL (1.2 and 1.4, respectively) (p<0.05). There were no differences in EBL in the SL, HA, and RA techniques (193, 291, and 259 min, respectively) (p > 0.05). OT was longer for RA (229 min) compared to SL and HA (187 and 198 min, respectively) (p < 0.05). WI time for HA (19.6 min) was shorter than for SL and RA (21.3 and 25.3 min, respectively) ( p < 0.05). LOS was longer for HA (3.1 days) when compared to SL and RA (2.4 and 2.3 days, respectively) (p <0.05). HA and SL had a higher overall incidence of Clavien-Dindo grade 3 and 4 post-operative complications compared to RA (15.3% vs 13.8% vs 1.5%, respectively) (p <0.05).
CONCLUSIONS: Our study demonstrates that at our tertiary care center, the RA approach is beginning to be used more frequently and is starting to overshadow traditional SL. The RA technique had a low incidence of post-operative complications, but the HA technique was used in more anatomically complex cases. We did not measure renal function pre and post-operatively, however, given the shorter WI time seen with the HA technique it can be better suited for patients looking for greater preservation of their renal function. More prospective studies comparing the three techniques are needed to validate our results.
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