比較達文西機械手臂輔助經腹腔式及後腹腔式部分腎臟切除手術之治療成效

陳人傑¹、鍾孝仁^1,2、黃志賢^1,2

¹臺北榮民總醫院 泌尿部; ²國立陽明交通大學醫學院 泌尿學科 書田泌尿科學研究中心

Comparison of Outcomes Between Transperitoneal and Retroperitoneal Robotic Assisted Laparoscopic Partial Nephrectomy

Jen-Chieh Chen¹, Hsiao-Jen Chung^1,2, William J. Huang^1,2

¹Department of Urology, Taipei Veterans General Hospital;

²Department of Urology, College of Medicine and Shu-Tien Urological Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan²

Purpose:

When performing robotic-assisted nephron-sparing surgery for renal tumors, either a transperitoneal or retroperitoneal approach can be utilized. A growing literature revealed that robotic-assisted retroperitoneal partial nephrectomy (RPPN) might be particularly advantageous for posterior and lateral renal tumors and was associated with decreased operative times and length of stay. Herein, we performed a matched paired analysis to compare the outcome of RPPN and transperitoneal partial nephrectomy (TPPN) in our institute.

Materials and Methods:

We retrospectively reviewed the electronic medical record of our patient database from December 2009 to July 2020. A total of 376 robotic-assisted laparoscopic partial nephrectomy (RAPN) procedures were performed by a single surgeon (HJ Chung) in 372 patients at the Department of Urology, Taipei Veterans General Hospital (4 patients received simultaneously bilateral RAPN). RPPN was performed in 35 patients (9.4%) and TPPN was performed in 337 patients (90.6%). Matched-paired analysis was performed, and the matching criteria used were age (± 5 years), gender, and PADUA score. There were a total of 34 matched pairs. The surgical parameters, outcome, and complications were analyzed. Two-sample t test and Kaplan-Meier method were used to analyze the data.

Results:

A total of 34 pairs matched with age, gender, and PADUA score were enrolled. The mean age was 55.4 years in RPPN group and 56.3 years in TPPN group. The average tumor size did not differ between groups (TPPN group: 3.9 ± 1.9 cm; RPPN group: 3.8 ± 1.5 cm, p = 0.806). Twenty-eight patients (82.4%) were diagnosed with renal cell carcinoma in RPPN group and twenty-five patients (73.5%) in TPPN group (p = 0.476). There was no significant difference in terms of pathologic staging between the two groups for each stage. The surgical margin was negative in all cases. The average operative time and console time are similar between RPPN and TPPN groups (283 vs. 260 minutes, p = 0.278; 181 vs. 191 minutes, p = 0.544). The average estimated blood loss was 151 ± 187 ml in RPPN group and 200 ± 224 ml in TPPN group (p = 0.334). The warm ischemia time was 22.8 ± 10.1 minutes in RPPN group and 23.9 ± 14.6 in TPPN group (p = 0.706). The length of stay was 4.5 ± 1.2 days in RPPN group and 5.1 ± 1.6 days in TPPN group (p = 0.09). Complications were also characterized and there was no overall difference in complication rates between the two groups (RPPN: 11.8%; TPPN = 5.9%, p = 0.673). Regarding the conversion rate, there was no conversion to open surgery or radical nephrectomy. The median follow-up was 27.5 months, and there was no survival difference (overall survival, cancer-specific survival, disease-free survival) between patients who received RPPN and TPPN.

Conclusions:

Both robotic RPPN and TPPN can be used for renal tumors with comparable results in term of operative time, console time, estimated blood loss, warm ischemia time, length of stay, complication, conversion rate, and survival outcome. Surgeon comfort and expertise will help determine which approach to use. A case-by-case consideration is important as well. Randomized controlled trials and high-quality observational studies are needed to confirm our findings.