Comfort level determines partial nephrectomy approach

Chicago-For the surgeon contemplating performing a minimally invasive partial nephrectomy, the choice of a pure laparoscopic, hand-assisted, or robot-assisted procedure boils down to selecting the approach that provides the highest comfort level for the surgeon.

It is a subjective decision, according to re-searchers at Hackensack University Medical Center, Hackensack, NJ, who presented their experience comparing the outcomes of the three procedures at the AUA annual meeting.

"There are specific differences between each of these laparoscopic approaches," study co-author Jayant Uberoi, MD, told Urology Times. "We believe that a surgeon should choose the procedure with which he or she is most comfortable. If the surgeon is proficient in all three procedures, he or she will likely encounter similar results, regardless of the approach chosen."

"During the past few years, a number of investigators have been exploring the role of robotics for kidney surgery. The robot seems to offer a distinct advantage for suturing during pyeloplasty procedures; however, there is debate as to whether the technology offers advantages over conventional laparoscopy for partial or total nephrectomy," he said, noting that Hackensack surgeons have substantial experience with all three approaches.

Using the medical center's database, the researchers retrospectively reviewed their 15 most recent cases each of pure laparoscopic partial nephrectomy (LPN), hand-assisted laparoscopic partial nephrectomy (HALPN), and robot-assisted laparoscopic partial nephrectomy (RALPN) procedures.

Analysis found no statistically significant differences in mean operative times (151–168 minutes), blood loss (157–198 mL), hospital stay (2.0–2.6 days), tumor size (2.0–2.3 cm), or warm ischemia time (21–24 minutes) among the three groups. Seventy-three percent of the lesions were found to be malignant. All surgical margins were negative, and there were no major complications in any case.

Uniquely different approaches

The authors note that each procedure has unique advantages and disadvantages. The advantages of HALPN are that it allows easy kidney mobilization and tumor exposure, facile suturing, and superior temporary hemostasis. However, the procedure requires a larger incision for tumor extraction, and there is an added cost for the hand-access device.

The pure laparoscopic procedure has the lowest cost and smallest incisions, but is the most technically challenging, and is associated with a fairly steep learning curve.

With three-dimensional high-definition vision, the robotic procedure offers the best optics of the three technologies. The maneuverability and precision of the robotic instruments allow for easier suturing and facilitate more complex tumor resection and reconstruction. It is also the costliest of the three, and the surgeon must rely on a skilled surgical assistant, especially for dissection and control of the renal blood vessels.

"In our opinion, the significant advantages of the robotic procedure are the ease of tumor resection and suturing capabilities for collecting system closure and parenchymal reconstruction. It offers the potential to tackle tumors that are more complex, such as those that are deep within the kidney or close to the renal hilum. In addition, the technology offers the benefits of 3-D, high-definition vision, which is not typically available with the other laparoscopic approaches," said Dr. Uberoi.

Differences in the learning curves for laparoscopic and robotic procedures can affect clinical decisions.

"The learning curve for the pure laparoscopic procedure is considerably steeper than that for the robotic procedure, so robotic assistance may actually enable some surgeons to perform a procedure that they may not have been able to do previously. It is conceivable that robotic surgery may allow for more rapid dissemination of minimally invasive partial nephrectomy, which would benefit both physicians and patients," said Dr. Uberoi, adding that at his institution, there was a trend toward surgeons conducting more partial nephrectomies robotically.

"The operative outcomes resulting from the three approaches are similar in the hands of a surgeon who is comfortable with all three," Dr. Munver said.