Purely off-clamp robotic partial nephrectomy

==inizio abstract==

In this video we describe our surgical technique, reporting perioperative, 3-yr oncologic and functional outcomes of a single centre series of 308 patients treated with robotic off-clamp PN (OFF-RPN).
Data of all patients underwent OFF-RPN between 2010 and 2015 in a high-volume centre were collected.
Patients were placed in an extended flank position and a 5-port access with a side docking was performed. Hilar vessels were not clamped in any case; pure tumour enucleation or enucleoresection were the resection techniques used; renorraphy was omitted for small and exophytic masses and minimized with a “point specific haemostasis” for hilar tumours.
Perioperative complications, 3-yr oncologic and functional outcomes were reported. Univariable and multivariable analyses were performed to identify independent predictors of RF deterioration.
Out of 308 patients treated, 41 (13.3%) experienced perioperative complications, 2.9% of which were Clavien grade ≥3. Three-yr local recurrence free survival and cancer specific survival rates were 99.5% and 97.9%, respectively.
No patient with preoperative CKD-stage ≤3B developed severe RF deterioration (CKD-stage 4) at 1-yr follow-up.
Preoperative eGFR (p=0.005) was the only independent predictor of a new onset CKD-stage ≥3 in patients with preoperative CKD-stages 1 or 2.
OFF-RPN is a safe surgical approach in tertiary referral centres, with adequate oncological outcomes and negligible impact on RF.

==fine abstract==

Enucleoresezione laparoscopica di Neoplasie Renali Cistiche (Cisti di Bosniak tipo III- IV)

==inizio abstract==

Le lesioni renali di tipo cistico sono di osservazione relativamente frequente e possono essere trattate con chirurgia nephron sparing quando le caratteristiche della massa lo consentono.
L’approccio laparoscopico viene talvolta limitato per il timore di disseminazione neoplastica. Nel video sono mostrati due casi di enucleoresezione laparoscopica di lesioni cistiche.
Il video mostra i casi clinici completi di iconografia preoperatoria e controllo a sei mesi, la tecnica di enucleoresezione viene condotta mantenendo un margine di tessuto renale sano di sicurezza e clampando l’ilo in caso di necessità.
La tecnica di sutura laparoscopica viene effettuata in singolo o doppio strato (midollare e corticale) a seconda delle necessità impiegando clips Haemolock per l’ancoraggio del filo impiegato (Vicryl 1 con ago ampio) o barbed sutures.
Impieghiamo sempre uno stent preoperatorio nella via escretrice.
Uno dei casi illustrati è stato complicato da una lesione ureterale riparata in continua contestualmente.
Il controllo TAC a sei mesi evidenzia remissione completa della malattia in assenza di recidive o disseminazione.
Nella nostra esperienza con un follow-up medio di tre anni su 8 lesioni di questo tipo trattate non si sono verificate recidive o ripresa di malattia a distanza.

==fine abstract==

ZERO ISCHEMIA FOR PARTIAL NEPHRECTOMY: A SAFE PROCEDURE FOR THE MANAGMENT OF SMALL KIDNEY TUMORS

==inizio objective==

Robotic partial nefrectomy (RPN) and laparoscopic partial nefrectomy ( LPN) are effective surgical treatments for small kidney tumors ( T1a– T1b) (1).
The aim of this retrospective study is to evaluate the effectivness of zero ischemia techinique in RPN and LPN for small renal masses.

==fine objective==

==inizio methodsresults==

We retrospectively evaluated 296 renal tumorectomy performed in our istitution. (198 LPN and 98 RPN).
We performed in all cases renal tumor enucleation. Tumor average size was 4,1 cm (7,2-1,2) and R.E.N.A.L. average score 5.1 (4-8).
The main outcome parameters examined were intraoperative blood loss, intraoperative and post-operative blood trasfusions and surgical conversion rate.

==fine methodsresults==

==inizio results==

All the RPN procedures were concluded without conversion to open surgery but 1 (1.05%). We performed RPN with clamp of renal artery in 3 caes (1,1 %) with R.E.N.A.L score 7 and 8 . 5 LPN (all with R.E.N.A.L score 7) were converted to open procedure (2.5%).
94 RPN and all the LPN were performed without vascular approach.
Intraoperative transfusion never occours in these series. Itraoperative average blood loss was 110 cc (10-260 cc) in RPN and 245 cc in LPN (20-460cc).
3 (1.1%) patients underwent to RPN and 15 (5%) after LPN were postoperatively trasfsused.

==fine results==

==inizio discussions==

In our experience most of LPN and RPN procedures were performed without clamping . Only three RPN procedures were performed with vascular approach and hilar clamping

==fine discussions==

==inizio conclusion==

Small renal masses with R.E.N.A.L score ≤ 6 enucleation can be performed without hilar clamping. Pedicle dissection can be safely avoided in these cases to reduce operative time and the consequent related risks.

==fine conclusion==

==inizio reference==

1 Curr Opin Urol. 2013 Sep;23(5):399-402. doi: 10.1097/MOU.0b013e3283632115.
Hilar clamping versus off-clamp laparoscopic partial nephrectomy for T1b tumors.
Kreshover JE1, Kavoussi LR, Richstone L.

==fine reference==

Purely Off-clamp Robotic Partial Nephrectomy: Preliminary 3-year Oncologic and Functional Outcomes

==inizio objective==

The negative impact of ischemia on renal function (RF) has led surgeons to develop minimally ischemic
techniques to perform partial nephrectomy (PN). We described our surgical technique and report perioperative, 3-yr oncologic and functional outcomes of a single centre series of 308 consecutive patients treated with robotic off-clamp PN (OFF-RPN).

==fine objective==

==inizio methodsresults==

A prospective renal cancer database was queried and data of all patients treated with OFF-RPN between 2010 and 2015 in a high-volume centre were collected.
Patients were placed in an extended flank position and a 5-port access with a side docking was performed. Hilar vessels were not clamped in any case; pure tumour enucleation or enucleoresection were the resection techniques used; renorraphy was omitted for small and exophytic masses and minimized with a point specific haemostasis†for hilar tumours.
Perioperative complications, 3-yr oncologic and functional outcomes were reported. Univariable and multivariable analyses were performed to identify independent predictors of RF deterioration.

==fine methodsresults==

==inizio results==

Out of 308 patients treated, 41 (13.3%) experienced perioperative complications, 2.9% of which were Clavien grade 3. Three-yr local recurrence free survival and renal cell carcinoma specific survival rates were 99.5% and 97.9%, respectively (Figure 1).
No patient with preoperative CKD-stage 3B developed severe RF deterioration (CKD-stage 4) at 1-yr follow-up (Figure2).
At multivariable analysis, preoperative eGFR (p=0.005) was the only independent predictor of a new onset CKD-stage 3 in patients with preoperative CKD-stages 1 or 2.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

OFF-RPN is a safe surgical approach in tertiary referral centres, with adequate oncological outcomes and negligible impact on RF.

==fine conclusion==

==inizio reference==

-Indications, techniques, outcomes, and limitations for minimally ischemic and off-clamp partial nephrectomy: a systematic review of the literature.
Simone G, Gill IS, Mottrie A, Kutikov A, Patard JJ, Alcaraz A, Rogers CG.
Eur Urol. 2015 Oct;68(4):632-40. doi: 10.1016/j.eururo.2015.04.020. Review

==fine reference==

Radical nephrectomy versus nephron sparing surgery: run after a chimera?

==inizio objective==

Literature data regarding oncological outcomes after radical nephrectomy and nephron sparing surgery are conflicting.
Van Poppel et al showed overlapping oncological data between radical nephrectomy (RN) and nephron sparing surgery (NSS), but NSS seems to provide lower OS results in comparison with RN [1] and slightly higher complication rate [2].
Moreover, a recent SEER database analysis conducted on a young population (20-44 yrs) showed no difference in cancer-specific survival at 5 or 10 years and in 5-year overall survival (P = 0.07), but a significative advantage in 10-year overall survival (P = 0.025) in partial nephrectomy cohort [3], whereas a retrospective study conducted on patients with T1 renal cancer documented that type of nephrectomy was not associated with overall survival [4]
The aim of our study was to compare the long-term oncological and functional outcome as well as the surgical complications of nephron sparing surgery (NSS) versus radical nephrectomy (RN) for any renal cell carcinoma (RCC) over all stages (T1-T4).

==fine objective==

==inizio methodsresults==

Between April 2000 and June 2016, 392 patients underwent renal surgery for RCC in two European academical centers.
129 women and 263 men with a median age of 65 years (range 23-88) underwent RN or NSS. 162/392 (41.3%) experienced a RN, whereas 239/392 (58.7%) underwent a NSS.
We compared long term overall survival (OS), cancer specific survival (CSS), disease free survival (DFS) in both groups of patients.
Moreover, functional parameters and surgical complications (according to Clavien Dindo classifications) were evaluated in the whole cohort.
Median follow-up time for these patients was 48.08 months (range 0.26-194.43).

==fine methodsresults==

==inizio results==

Compared to RN, patients with NSS showed a significantly higher disease free survival (DFS) (70.2% vs 93.5%, p<0.001) and cancer specific survival (CSS) at 10 years (78.4% vs 97.8%, p<0.001), whereas the 10 years overall survival (OS) in both groups did not differ significantly (RN 65.3% vs NSS 71.3%, p= n.s.). 4% of NSS had a positive resection margin (PRM), but only 0.4% developed a recurrence within 23 months. Within the follow up period, 7% of patients in the NSS group developed metastases VS 28.1% of the RN group. At the last follow up, renal function preservation, moreover, was better in the NSS group, with a median glomerular filtration rate of 65 ml/min/1.72m2 (6-113) for NSS VS. 54 ml/min/1.72m2 (1.73-144) for RN (p<0.001). The new onset of chronic kidney diseases was significantly less in the NSS group. Total complication rate was significantly lower in the RN group (5.6% vs 8.9%), but became comparable in the last years of observation. ==fine results== ==inizio discussions== Contrary to the literature data, our study showed an advantage in term of CSS and DFS in the NSS group, with no significative effects on OS, and with an acceptable complication rate. ==fine discussions== ==inizio conclusion== NSS was performed whenever technically possible but was obtained with a higher (but acceptable) surgical complication rate. It could be shown that also for higher stages of RCC, NSS can be safely performed. Renal function preservation, CSS and DFS were better in the NSS group but surprisingly NSS did not lead to a better OS. This stands in contrast to the most published studies of the last decades. ==fine conclusion== ==inizio reference== 1. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2011 Apr;59(4):543-52. 2. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2007 Jun;51(6):1606-15. 3. Daugherty M, Bratslavsky G. Compared with radical nephrectomy, nephron-sparing surgery offers a long-term survival advantage in patients between the ages of 20 and 44 years with renal cell carcinomas (≤4 cm): an analysis of the SEER database Urol Oncol. 2014 Jul;32(5):549-54. 4. Kyung YSm You D, Kwon T et al The type of nephrectomy has little effect on overall survival or cardiac events in patients of 70 years and older with localized clinical t1 stage renal masses. Korean J Urol. 2014 Jul;55(7):446-52. ==fine reference==