title: Perioperative and renal functional outcomes of elective robot-assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity.
abstract: OBJECTIVE
  To evaluate the perioperative, postoperative and functional outcomes of robot-assisted partial nephrectomy (RAPN) for renal tumours with high surgical complexity at a large volume centre.
  
  
  METHODS
  Perioperative and functional outcomes of RAPNs for renal tumours with a Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score of ≥10 performed at our institution between September 2006 and December 2012 were collected in a prospectively maintained database and analysed. Surgical complications were graded according to the Clavien-Dindo classification. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at the third postoperative day and 3-6 months after RAPN.
  
  
  RESULTS
  In all, 44 RAPNs for renal tumours with PADUA scores of ≥10 were included in the analysis; 23 tumours (52.3%) were cT1b. The median (interquartile range; range) operative time, estimated blood loss and warm ischaemia time (WIT) were 120 (94, 132; 60-230) min, 150 (80, 200; 25-1200) mL and 16 (13.8, 18; 5-35) min, respectively. Two intraoperative complications occurred (4.5%): one inferior vena caval injury and one bleed from the renal bed, which were both managed robotically. There were postoperative complications in 10 patients (22.7%), of whom four (9.1%) were high Clavien grade, including two bleeds that required percutaneous embolisation, one urinoma that resolved with ureteric stenting and one bowel occlusion managed with laparoscopic adhesiolysis. Two patients (4.5%) had positive surgical margins (PSMs) and were followed expectantly with no radiological recurrence at a mean follow-up of 23 months. The mean serum creatinine levels were significantly increased after surgery (121.1 vs 89.3 μmol/L; P = 0.001), but decreased over time, with no significant differences from the preoperative values at the 6-month follow-up (96.4 vs 89.3 μmol/L; P = 0.09). The same trend was seen for eGFR.
  
  
  CONCLUSIONS
  In experienced hands RAPN for renal tumours with a PADUA score of ≥10 is feasible with short WIT, acceptable major complication rate and good long-term renal functional outcomes. A slightly higher risk of PSMs can be expected due to the high surgical complexity of these lesions. The robotic technology allows a safe expansion of the indications of minimally invasive PN to anatomically very challenging renal lesions in referral centres.
authors.affiliation: Division of Urology, O.L.V. Vattikuti Robotic Surgery Institute, Aalst, Belgium; Division of Urology, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Volpe
authors.forename: Diletta
authors.initials: D
authors.lastname: Garrou
authors.forename: Daniele
authors.initials: D
authors.lastname: Amparore
authors.forename: Geert
authors.initials: G
authors.lastname: De Naeyer
authors.forename: Francesco
authors.initials: F
authors.lastname: Porpiglia
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ficarra
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mottrie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007668:Kidney / Q000502:physiology / Q000601:surgery; D007680:Kidney Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome
keywords: PADUA score; carcinoma; nephron-sparing surgery; outcomes; renal cell; robotic partial nephrectomy