Robotic radical nephrectomy: Really?

Two recent studies highlight the increasing use of robotic radical nephrectomy in the United States. Using the Nationwide Inpatient Sample, Weinberg and associates found that the proportion of radical nephrectomies (RNs) performed robotically in the U.S. increased from 2% to 8% from 2008 to 2010 (see "Use of robotic RN rising, despite unclear advantages"). Yang et al, using the same database, determined that among the minimally invasive RNs performed in the U.S. from 2009 to 2011, 71% were laparoscopic (LRN) and 29% were robotic (RRN) (J Urol 2014; 191:e58-59). They found no differences in comorbidities, perioperative complications, or mortality between the two procedures. RRN was associated with an $11,267 (~29%) increase in charges.

None of the comparative studies of RRN and LRN has shown benefit of RRN over LRN. Why then are so many minimally invasive RNs performed this way? There are many possible reasons: to gain experience with robotic surgery, to increase robot utilization, to market the procedure, and others. Unfortunately, none of these reasons makes up for the high cost of RRN, which includes not only the cost of the robot and limited-use instruments but also the expense of the necessary experienced bedside assistant.

An additional motivation is that some surgeons may not be facile with standard LRN and, wanting to provide a minimally invasive alternative, feel that they need the robot to provide that. In my opinion, this justification applies to such procedures as prostatectomy, radical cystectomy, partial nephrectomy, and pyeloplasty-reconstructive procedures that take advantage of the robot’s capabilities. In the case of RN, however, there is a mature and robust experience with hand-assisted LRN, which has been shown repeatedly to provide results similar to standard LRN but with a much shorter learning curve. If minimally invasive RN is desired and standard LRN is not within the skill set, then I suggest hand-assisted LRN over RRN.

RRN is a reasonable choice for RN associated with vena caval tumor thrombectomy, to facilitate single-site surgery, and in the unusual case of a renal cancer patient who is concerned about the extra few centimeters of incision for hand-assisted LRN (if standard LRN is not an option). Beyond that, frankly, RRN does not make any sense.UT

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