A variety of surgical and nonsurgical management options for small renal masses (SRMs) now exist. Surgery in the form of partial nephrectomy (PN) has three different approaches. It is unclear which PN approach, if any, offers superior clinical outcomes.
Aim:
The aim of this study is to compare outcomes in patients with SRMs <4 cm undergoing PN through the open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), or robotic partial nephrectomy (RPN) approach and to establish the advantages and disadvantages of the various approaches.
Methods:
A systematic literature search was conducted for studies comparing at least two of the above techniques. Eighteen studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed. OPN was used as the baseline comparator. The prespecified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay, and recurrence.
Results:
There was no significant difference between the techniques in terms of R0 rates, tumor recurrence, urine leak rates, renal function, and >3a Clavien–Dindo complications. LPN had a longer ischemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates.
Discussion:
All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischemic time and operative duration. Variations between perioperative outcomes may influence the choice of approach on a case-by-case and institutional basis.
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References
1.
SungH, FerlayJ, SiegelRL, et al.Global Cancer Statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2021; 71(3):209–249.
RossiSH, KlatteT, Usher-SmithJ, et al.Epidemiology and screening for renal cancer. World J Urol, 2018; 36(9):1341–1353.
4.
Sánchez-MartínFM, Millán-RodríguezF, Urdaneta-PignalosaG, et al.Small renal masses: Incidental diagnosis, clinical symptoms, and prognostic factors. Adv Urol, 2008; 2008:310694.
5.
StakhovskyiO, YapSA, LeveridgeM, et al.Small renal mass: What the urologist needs to know for treatment planning and assessment of treatment results. Am J Roentgenol, 2011; 196(6):1267–1273.
6.
ThompsonRH, HillJR, BabayevY, et al.Metastatic renal cell carcinoma risk according to tumor size. J Urol, 2009; 182(1):41–45.
7.
SceloG, LaroseTL. Epidemiology and risk factors for kidney cancer. J Clin Oncol, 2018; 36(36):JCO2018791905-JCO.
RichardPO, LavalléeLT, PouliotF, et al.Is routine renal tumor biopsy associated with lower rates of benign histology following nephrectomy for small renal masses?. J Urol, 2018; 200(4):731–736.
10.
MarconiL, DabestaniS, LamTB, et al.Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol, 2016; 69(4):660–673.
11.
HerrHW.A history of partial nephrectomy for renal tumors. J Urol, 2005; 173(3):705–708.
12.
CozarJM, TalladaM. Open partial nephrectomy in renal cancer: A feasible gold standard technique in all hospitals. Adv Urol, 2008; 2008:916463.
13.
CwachK, KavoussiL. Past, present, and future of laparoscopic renal surgery. Investig Clin Urol, 2016; 57(Suppl 2):S110–S113.
14.
GettmanMT, BluteML, ChowGK, et al.Robotic-assisted laparoscopic partial nephrectomy: Technique and initial clinical experience with DaVinci robotic system. Urology, 2004; 64(5):914–918.
15.
SimoneG, De NunzioC, FerrieroM, et al.Trends in the use of partial nephrectomy for cT1 renal tumors: Analysis of a 10-yr European multicenter dataset. Eur J Surg Oncol, 2016; 42(11):1729–1735.
16.
CampbellS, UzzoRG, AllafME, et al.Renal mass and localized renal cancer: AUA guideline. J Urol, 2017; 198(3):520–529.
17.
LjungbergB, AlbigesL, Abu-GhanemY, et al.European Association of Urology Guidelines on renal cell carcinoma: The 2019 update. Eur Urol, 2019; 75(5):799–810.
18.
GunnAJ, GervaisDA. Percutaneous ablation of the small renal mass-techniques and outcomes. Semin Intervent Radiol, 2014; 31(1):33–41.
19.
UhligJ, StraussA, RückerG, et al.Partial nephrectomy versus ablative techniques for small renal masses: A systematic review and network meta-analysis. Eur Radiol, 2019; 29(3):1293–1307.
20.
ZhongJ, WahTM. Renal ablation: Current management strategies and controversies. Chinese Clin Oncol, 2019; 8(6):63.
21.
FinelliA, IsmailaN, BroB, et al.Management of small renal masses: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol, 2017; 35(6):668–680.
22.
ChoiJE, YouJH, KimDK, et al.Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: A systematic review and meta-analysis. Eur Urol, 2015; 67(5):891–901.
23.
YouC, DuY, WangH, et al.Laparoscopic versus open partial nephrectomy: A systemic review and meta-analysis of surgical, oncological, and functional outcomes. Front Oncol, 2020; 10:583979.
24.
JansenJP, NaciH. Is network meta-analysis as valid as standard pairwise meta-analysis? It all depends on the distribution of effect modifiers. BMC Med, 2013; 11(1):159.
HigginsJP, AltmanDG, GøtzschePC, et al.The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ, 2011; 343:d5928.
27.
HuttonB, SalantiG, CaldwellDM, et al.The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations. Ann Intern Med, 2015; 162(11):777–784.
28.
StroupDF, BerlinJA, MortonSC, et al.Meta-analysis of observational studies in epidemiology: A proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA, 2000; 283(15):2008–2012.
29.
MotzerRJ, JonaschE, BoyleS, et al.NCCN Guidelines Insights: Kidney cancer, version 1.2021: Featured updates to the NCCN guidelines. J Natl Compr Canc Netw, 2020; 18(9):1160–1170.
30.
HozoSP, DjulbegovicB, HozoI. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005; 5:13.
31.
LuoD, WanX, LiuJ, et al.Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res, 2018; 27(6):1785–1805.
32.
RückerG.Network meta-analysis, electrical networks and graph theory. Res Synth Methods, 2012; 3(4):312–324.
33.
SchwarzerG, CarpenterJR, RückerG.Meta-Analysis with R. Springer; 2015. Available from: https://link.springer.com/book/10.1007/978-3-319-21416-0
34.
ChangW, ChengJ, AllaireJ, et al.Shiny: Web application framework for R. R Package Version; 2017. Available from: https://cran.r-project.org/web/packages/shiny/index.html
35.
SpiegelhalterDJ, BestNG, CarlinBP, et al.Bayesian measures of model complexity and fit. J R Stat Soc Series B Stat Methodol, 2002; 64(4):583–639.
36.
HozoSP, DjulbegovicB, HozoI. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005; 5:13.
37.
LuoD, WanX, LiuJ, et al.Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res, 2018; 27(6):1785–1805.
38.
WanX, WangW, LiuJ, et al.Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol, 2014; 14(1):135.
39.
SalantiG, Del GiovaneC, ChaimaniA, et al.Evaluating the quality of evidence from a network meta-analysis. PLoS One, 2014; 9(7):e99682.
40.
AronM, KoenigP, KaoukJH, et al.Robotic and laparoscopic partial nephrectomy: A matched-pair comparison from a high-volume centre. BJU Int, 2008; 102(1):86–92.
41.
BeasleyKA, Al OmarM, ShaikhA, et al.Laparoscopic versus open partial nephrectomy. Urology, 2004; 64(3):458–461.
42.
CastleSM, GorbatiyV, AvalloneMA, et al.Cost comparison of nephron-sparing treatments for cT1a renal masses. Urol Oncol, 2013; 31(7):1327–1332.
43.
DarTI, TyagiV, SharmaA, et al.Robotic-assisted versus laparoscopic partial nephrectomy: An experience with a novel technique of suturing. Saudi J Kidney Dis Transpl, 2015; 26(4):684–691.
44.
GongEM, OrvietoMA, ZornKC, et al.Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors. J Endourol, 2008; 22(5):953–957.
45.
LucasSM, MellonMJ, ErntsbergerL, et al.A comparison of robotic, laparoscopic and open partial nephrectomy. JSLS, 2012; 16(4):581–587.
46.
MalkocE, MauriceMJ, KaraO, et al.Robot-assisted approach improves surgical outcomes in obese patients undergoing partial nephrectomy. BJU Int, 2017; 119(2):283–288.
47.
MinerviniA, SienaG, AntonelliA, et al.Open versus laparoscopic partial nephrectomy for clinical T1a renal masses: A matched-pair comparison of 280 patients with TRIFECTA outcomes (RECORd Project). World J Urol, 2014; 32(1):257–263.
48.
MouravievV, NosnikI, RobertsonC, et al.Comparative financial analysis of minimally invasive surgery to open surgery for small renal tumours < or = 3.5 cm: A single institutional experience. Eur Urol, 2007; 51(3):715–720; discussion 20–21.
49.
OhJJ, LeeJK, KimK, et al.Comparison of the width of peritumoral surgical margin in open and robotic partial nephrectomy: A propensity score matched analysis. PLoS One, 2016; 11(6):e0158027.
50.
ParkH, ByunSS, KimHH, et al.Comparison of laparoscopic and open partial nephrectomies in t1a renal cell carcinoma: A Korean multicenter experience. Korean J Urol, 2010; 51(7):467–471.
51.
RamirezD, MauriceMJ, CaputoPA, et al.Predicting complications in partial nephrectomy for T1a tumours: Does approach matter?. BJU Int, 2016; 118(6):940–945.
52.
RezaeetalabGH, KaramiH, DadkhahF, et al.Laparoscopic versus open partial nephrectomy for stage T1a of renal tumors. Urol J, 2016; 13(6):2903–2907.
53.
SimsekA, YavuzsanAH, ColakogluY, et al.Comparison of robotic and laparoscopic partial nephrectomy for small renal tumours. Arch Ital Urol Androl, 2017; 89(2):93–96.
54.
TabayoyongW, AbouassalyR, KiechleJE, et al.Variation in surgical margin status by surgical approach among patients undergoing partial nephrectomy for small renal masses. J Urol, 2015; 194(6):1548–1553.
55.
WangAJ, BhayaniSB. Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: Single-surgeon analysis of >100 consecutive procedures. Urology, 2009; 73(2):306–310.
56.
YooS, LeeC, LeeC, et al.Comparison of renal functional outcomes in exactly matched pairs between robot-assisted partial nephrectomy using warm ischemia and open partial nephrectomy using cold ischemia using diethylene triamine penta-acetic acid renal scintigraphy. Int Urol Nephrol, 2016; 48(5):687–693.
57.
ZargarH, AllafME, BhayaniS, et al.Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: A multi-institutional study. BJU Int, 2015; 116(3):407–414.
58.
KottO, GolijaninB, PereiraJF, et al.The BMI paradox and robotic assisted partial nephrectomy. Front Surg, 2020; 6:74.
59.
KhalilMI, UbedaJ, SoehnerT, et al.Contemporary perioperative morbidity and mortality rates of minimally invasive vs open partial nephrectomy in obese patients with kidney cancer. J Endourol, 2019; 33(11):920–927.
60.
IsacWE, AutorinoR, HillyerSP, et al.The impact of body mass index on surgical outcomes of robotic partial nephrectomy. BJU Int, 2012; 110(11c):E997–E1002.
61.
MalikVS, WilletWC, HuFB. Nearly a decade on—Trends, risk factors and policy implications in global obesity. Nat Rev Endocrinol, 2020; 16(11):615–616.
62.
BuseS, HachCE, KlumpenP, et al.Cost-effectiveness of robot-assisted partial nephrectomy for the prevention of perioperative complications. World J Urol, 2016; 34(8):1131–1137.
63.
BuseS, HachCE, KlumpenP, et al.Cost-effectiveness analysis of robot-assisted vs. open partial nephrectomy. Int J Med Robot, 2018; 14(4):e1920.
64.
LarcherA, MuttinF, PeyronnetB, et al.The learning curve for robot-assisted partial nephrectomy: Impact of surgical experience on perioperative outcomes. Eur Urol, 2019; 75(2):253–256.
