Journal Article Page
Jump to
European Urology
Volume 57, issue 2, pages 179-362, February 2010Kidney Cancer
Robotic Partial Nephrectomy for Renal Tumors Larger Than 4 cm
Manish N. Patel, L. Spencer Krane, Akshay Bhandari, Rajesh G. Laungani, Alok Shrivastava, Sameer A. Siddiqui, Mani Menon, Craig G. Rogers 
.
Accepted 3 November 2009, Published online 13 November 2009, pages 310 - 316
Abstract Full-Text PDF (236 KB) Create Platinum Slide Series Place a comment
Abstract
Background
Minimally invasive partial nephrectomy (PN) is most commonly performed for renal tumors ≤4 cm in size. Robotic PN (RPN) for tumors >4 cm has not been assessed.
Objective
To evaluate the safety and feasibility of RPN for tumors >4 cm in the context of patients undergoing RPN for tumors ≤4 cm.
Design, setting, and participants
We reviewed data for 71 consecutive patients who underwent transperitoneal RPN at a tertiary care center between August 2007 and September 2009 by a single surgeon. Patients were stratified into two groups: 15 with tumors >4 cm on preoperative imaging (group 1) and 56 patients with tumors ≤4 cm (group 2).
Intervention
All patients underwent transperitoneal RPN by a single surgeon.
Measurements
Preoperative, perioperative, pathologic, and functional outcomes data were analyzed and compared between groups. We used χ2 and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant.
Results and limitations
Mean radiographic tumor size was 5.0 cm (4.1–7.9) for group 1 and 2.1 cm (0.7–3.8) for group 2. No significant differences were found between groups for estimated blood loss, total operative time, hospital stay, complication rates, and change in estimated glomerular filtration rate. Patients with larger tumors had longer median warm ischemia times (25 vs 20 min; p = 0.011). Limitations of our study include the retrospective nature the analysis, small sample size, and single-surgeon experience.
Conclusions
In our initial experience, RPN for tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment.
Keywords: Renal cell carcinoma, Robotic partial nephrectomy, Warm ischemia.
Article Outline
1. Introduction
Nephron-sparing surgery has become an established approach for small renal tumors, demonstrating equivalent oncologic efficacy to radical nephrectomy (RN) [1], [2], and [3] with the advantage of preservation of renal function and possibly improved survival. Laparoscopic partial nephrectomy (LPN) has demonstrated comparable oncologic and functional outcomes to open partial nephrectomy (OPN) [4]; however, partial nephrectomy (PN) for larger tumors may pose additional technical challenges during surgery. OPN has been described for patients with tumors >4 cm in size with satisfactory results [3]. LPN has also been described for patients with tumors >4 cm [5], and [6], but technical challenges may be even more pronounced with a laparoscopic approach than with an open approach.
Robotic assistance during PN is a relatively new approach, with a number of studies demonstrating its feasibility and safety for small renal tumors [7], [8], [9], and [10]. To the best of our knowledge, no studies evaluate robotic PN (RPN) for tumors >4 cm. We evaluate early surgical, functional, and oncologic outcomes of RPN for renal tumors >4 cm on preoperative imaging and compare these results to outcomes for tumors ≤4 cm.
2. Patients and methods
Data for 71 consecutive patients who underwent transperitoneal RPN at our institution between August 2007 and September 2009 by a single surgeon (CGR) were reviewed from a prospectively maintained, institutional review board–approved database. Tumor size was assessed preoperatively with either computed tomography or magnetic resonance imaging. Patients were stratified into two groups based on clinical tumor size: 15 patients with tumors >4 cm (group 1) and 56 patients with tumors ≤4 cm (group 2).
Preoperative demographic factors analyzed included age, gender, surgical side, body mass index, American Society of Anesthesiologists classification, and a history of previous abdominal surgery. The location, endophytic nature, and proximity to the collecting system of the tumor were assessed using preoperative imaging. The number of procedures performed for incidentally discovered masses and imperative indications (solitary kidney, bilateral renal masses, stage 3 or worse chronic kidney disease) was also assessed.
Our RPN technique has been described elsewhere, and a detailed description of technique is beyond the scope of this report [11], [12], and [13]. Briefly, patients are placed in flank position, and ports are placed as demonstrated in Fig. 1. The da Vinci robot system (Intuitive Surgical, Sunnyvale, CA, USA) is used in all cases. For large or challenging tumors, a four-arm approach is used. The fourth robotic arm can be used for tasks such as providing kidney retraction, placing the kidney on stretch for dissection of renal vessels, and positioning the kidney for optimal tumor resection.
01166-X/assets/gr1.jpg)
Bowel mobilization and kidney exposure are performed with complete robotic assistance. The renal hilum is dissected, and the perinephric fat is reflected to expose the capsule and tumor. Laparoscopic ultrasonography is used to confirm tumor location, extent, and depth, with real-time imaging displayed in the viewfinder using TilePro software (Intuitive Surgical, Sunnyvale, CA, USA). The renal capsule is scored to demarcate margins of resection. Hilar occlusion is performed in the majority of cases using either laparoscopic bulldog clamps or a Satinsky clamp.
For large, endophytic, or central tumors, we generally clamp both the artery and the vein. For small, peripheral, cortical tumors, we may clamp the artery alone. Tumor excision is performed sharply with robotic scissors, ensuring adequate surgical margins. Large vessels and collecting system defects are oversewn using 3-0 or 4-0 monocryl or polyglactin sutures with a Lapra-Ty (Ethicon, Cincinnati, OH, USA) clip instead of tied knots. In our early experience, the renal capsule was reapproximated using 0 polyglactin sutures anchored with Lapra-Ty clips, transitioning later to Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC, USA) with the sliding clip renorrhaphy technique. The opposite side is secured by a Hem-o-lok clip that the console surgeon slides down to reapproximate capsular edges under tension [14]. For larger tumors leaving a broad defect, bolsters and thrombogenic agents may be used.
Perioperative factors analyzed included total operative time (including abdominal insufflation, port placement, robot docking, specimen extraction, and closure), warm ischemia time, hilar clamping technique, estimated blood loss (EBL), conversion rate, change in 24-h postoperative hemoglobin, length of hospital stay, and length of follow-up. Complications were recorded using the Clavien classification system [15]. Change in estimated glomerular filtration rate (GFR) from baseline was assessed 24 h postoperatively and at follow-up of 1–3 mo postoperatively using the Modification of Diet in Renal Disease equation [16]. Pathologic factors analyzed included pathologic tumor size, histology, pathologic stage using the 2002 American Joint Committee on Cancer staging criteria, Fuhrman grade, and positive surgical margin (PSM) rate.
Preoperative and perioperative results as well as pathologic and functional outcomes data were retrospectively analyzed and compared between groups. Statistical analysis was performed using Stata v.10 (StataCorp, College Station, TX, USA). Comparisons between groups were performed using χ2 and student t tests for categorical and continuous variables, respectively. A p value <0.05 was considered statistically significant.
3. Results
A total of 71 patients underwent transperitoneal RPN at our institution during the study period, of which 15 patients had tumors >4 cm on preoperative imaging. Baseline demographics and radiographic tumor characteristics are summarized in Table 1. There was no significant difference in baseline characteristics between groups. Mean radiographic size was 5.0 cm (range: 4.1–7.9) and 2.1 cm (range: 0.7–3.8) for groups 1 and 2, respectively (p < 0.001).
Table 1 Preoperative variables for patients undergoing robotic partial nephrectomy
| Characteristic | Group 1 (>4 cm) | Group 2 (≤4 cm) | p value | |
|---|---|---|---|---|
| Patients, no. | 15 | 56 | – | |
| Demographic variables | ||||
| Mean age, yr (range) | 59.0 (44–76) | 60.1 (35–81) | 0.657 | |
| Gender, No. (%) | Male | 9 (60) | 35 (62.5) | 0.859 |
| Female | 6 (40) | 21 (37.5) | – | |
| Tumor side, No. (%) | Left | 9 (60) | 37 (66.1) | 0.662 |
| Right | 6 (40) | 19 (33.9) | – | |
| Mean BMI, kg/m2 (range) | 32.1 (18.4–48.8) | 30.6 (20.5–49) | 0.726 | |
| ASA classification score, No. (%) | 1 | 0 (0) | 1 (2.0) | 0.852 |
| 2 | 5 (41.7) | 18 (36.7) | – | |
| 3 | 7 (58.3) | 30 (61.2) | – | |
| Previous abdominal surgery, No. (%) | Yes | 2 (13.3) | 15 (26.8) | 0.278 |
| No | 13 (86.6) | 41 (73.2) | – | |
| Incidental finding, No. (%) | Yes | 11 (73.3) | 41 (73.2) | 0.993 |
| No | 4 (26.7) | 15 (26.8) | – | |
| Imperative indication for PN, No. (%) | Yes | 1 (6.6) | 7 (12.5) | 0.526 |
| No | 14 (93.3) | 49 (87.5) | – | |
| Radiographic variables | ||||
| Mean tumor size, cm (range) | 5.0 (4.1–7.9) | 2.1 (0.7–3.8) | <0.001 | |
| Tumor location, No. (%) | Upper | 7 (46.6) | 18 (32.1) | 0.427 |
| Mid | 4 (26.6) | 25 (44.6) | – | |
| Lower | 4 (26.6) | 13 (23.2) | – | |
| Percent endophytic, No. (%) | <50% | 11 (84.6) | 28 (53.8) | 0.115 |
| 50– <100% | 2 (15.3) | 19 (36.5) | – | |
| 100% | 0 (0) | 5 (9.6) | – | |
| Abutting collecting system, No. (%) | Yes | 10 (71.4) | 31 (55.3) | 0.275 |
| No | 4 (26.6) | 25 (44.6) | – | |
BMI = body mass index; ASA = American Society of Anesthesiologists; PN = partial nephrectomy.
Perioperative variables are summarized in Table 2. Intraoperative variables, including EBL, clamping technique, and conversion rate, were similar between groups. One patient in group 2 with normal renal function and a normal contralateral kidney was electively converted from RPN to robotic RN because of an intraoperative finding of multifocal, satellite lesions positive for renal cell carcinoma (RCC) on frozen section and poorly visualized on intraoperative ultrasound. The majority of cases in both groups were performed under warm ischemia (86.6% vs 78.5%; p = 0.400). Median warm ischemia time was longer for tumors >4 cm (25 vs 20 min; p = 0.011). Median total operative time was also longer for tumors >4 cm (275.5 vs 238 min) but did not reach statistical significance (p = 0.068). No patients required an intraoperative blood transfusion. Postoperative factors were similar between groups with regard to hospital stay, change in 24-h postoperative hemoglobin, and follow-up. The overall mean follow-up for our study was 6.8 mo, with the longest follow-up to date at 25 mo. There has been no disease-specific mortality in our series to date.
Table 2 Perioperative variables for patients undergoing robotic partial nephrectomy
| Characteristic | Group 1 | Group 2 | p value | |
|---|---|---|---|---|
| (>4 cm) | (≤4 cm) | |||
| Intraoperative variables | ||||
| Median total operative time, min (IQR) | 275.5 (229–344) | 238 (210–289) | 0.068 | |
| Median warm ischemia time, min (IQR) | 25 (20–30) | 20 (14–24.5) | 0.011 | |
| Median EBL, ml (IQR) | 100 (75–200) | 100 (50–200) | 0.287 | |
| Elective conversions, No. (%) | 0 (0) | 1 (1.8) | 0.602 | |
| Clamping technique, No. (%) | None | 2 (13.3) | 12 (21.4) | 0.400 |
| Bulldog | 13 (86.6) | 40 (71.4) | – | |
| Satinsky | 0 (0) | 4 (7.1) | – | |
| Collecting system repair, No. (%) | Yes | 10 (71.4) | 31 (55.3) | 0.275 |
| No | 4 (26.6) | 25 (44.6) | – | |
| Postoperative variables | ||||
| Median length of stay, d (IQR) | 2 (2–4) | 2 (2–3) | 0.197 | |
| Mean change in 24-h hemoglobin, g/dl (range) | −2.4 (−4.5 to −0.9) | −1.7 (−4.0 to 0.7) | 0.259 | |
| Mean follow-up, mo (range) | 7.9 (0.7–25.0) | 6.5 (0.3–19.3) | 0.286 | |
IQR = interquartile range; EBL = estimated blood loss.
A detailed comparison of intraoperative and postoperative complications is summarized in Table 3. Four complications occurred in group 1, including two postoperative urine leaks and two bleeds. Six complications occurred in group 2, including an intraoperative enterotomy (repaired robotically without sequelae), postoperative pneumonia, pulmonary embolism, and bleeding. There was no difference in intraoperative complications between groups (p = 0.602). Postoperative complications were higher for tumors >4 cm (26.6% vs 8.9%), although this difference did not reach statistical significance (p = 0.067). There was no difference in the severity of complications between groups based on the Clavien classification (p = 0.522). Renal function at baseline, postoperatively, and at follow-up is summarized in Table 4. Estimated GFR was higher preoperatively in group 1 (86.2 vs 73.5 ml/min per 1.73 m2; p = 0.447) but lower 24 h postoperatively (58.4 vs 68.9 ml/min per 1.73 m2; p = 0.19) and at 1–3-mo follow-up (74.0 vs 76.5 ml/min per 1.73 m2; p = 0.339), but none of these differences was statistically significant. Mean change in 24-h and 1–3-mo postoperative estimated GFR from baseline were greater for tumors >4 cm, but neither of these changes reached statistical significance (p = 0.295 and 0.063, respectively).
Table 3 Comparison of intraoperative and postoperative complications
| Group 1 | Group 2 | p value | |
|---|---|---|---|
| (>4 cm) | (≤4 cm) | ||
| Intraoperative complication, No. (%) | |||
| No | 15 (100) | 55 (98.2) | 0.602 |
| Yes | 0 (0) | 1 (1.8) | – |
| Postoperative complication, No. (%) | |||
| No | 11 (73.3) | 51 (91.1) | 0.067 |
| Yes | 4 (26.6) | 5 (8.9) | – |
| Complication | |||
| Intraoperative, No. (%) | |||
| Enterotomy* | 0 (0) | 1 (1.8) | – |
| Postoperative, No. (%) | |||
| Atelectasis | 0 (0) | 1 (1.8) | – |
| Urinary retention | 0 (0) | 1 (1.8) | – |
| Urine leak** | 2 (13.2) | 0 (0) | – |
| Bleeding† | 2 (13.2) | 2 (3.6) | – |
| Pulmonary embolism | 0 (0) | 1 (1.8) | – |
| Postoperative complications (Clavien classification), No. (%) | |||
| 1 | 0 (0) | 2 (3.6) | 0.522 |
| 2 | 1 (6.6) | 1 (1.8) | – |
| 3a | 2 (13.2) | 1 (1.8) | – |
| 3b | 0 (0) | 0 (0) | – |
| 4a | 1 (6.6) | 1 (1.8) | – |
| 4b | 0 (0) | 0 (0) | – |
| 5 | 0 (0) | 0 (0) | – |
*
**
†
Table 4 Change in renal function in patients undergoing robotic partial nephrectomy*
| Group 1 (>4 cm) | Group 2 (≤4 cm) | p value | |
|---|---|---|---|
| (n = 9) | (n = 28) | ||
| Mean baseline estimated GFR, No. (range) | 86.2 (57.3–168.7) | 73.5 (37.5–107.0) | 0.447 |
| Mean 24-h postoperative estimated GFR, No. (range) | 58.4 (33.3–97.3) | 68.9 (37.5–113.4) | 0.119 |
| Mean change in 24-h postoperative estimated GFR from baseline, No. (range) | −13.9 (−102.5 to 64.2) | −4.6 (−30.7 to 32.0) | 0.295 |
| Mean follow-up estimated GFR (1–3 mo), No. (range) | 74.0 (33.3–168.7) | 76.5 (27.4–126.9) | 0.339 |
| Mean change in follow-up estimated GFR (1–3 mo) from baseline, No. (range) | −12.3 (−64.2 to 28.6) | 3.0 (−37.3 to 64.8) | 0.063 |
GFR = glomerular filtration rate.
*
Final pathology revealed malignant tumors in 66.6% and 73.2% of patients in groups 1 and 2, respectively. Comparisons of pathologic variables are shown in Table 5. Mean pathologic tumor size was 5.2 cm (range: 3.6–8.1) versus 2.1 cm (range: 0.8–4.2) for groups 1 and 2, respectively (p < 0.001). There were three focal microscopic positive surgical margin (PSM) in group 2, of which two patients had undergone enucleation for angiomyolipoma, resulting in an overall PSM rate of 1.96% for malignancy. The patient is undergoing close observation with no evidence of local recurrence at 12-mo follow-up. There were no grossly positive margins.
Table 5 Pathologic variables for patients undergoing robotic partial nephrectomy
| Characteristic | Group 1 (>4 cm) | Group 2 (≤4 cm) | p value | |
|---|---|---|---|---|
| All patients | ||||
| Histology, No. (%) | RCC | 10 (66.6) | 41 (73.2) | 0.813 |
| AML | 3 (20) | 6 (10.7) | – | |
| Oncocytoma | 1 (6.6) | 4 (7.1) | – | |
| Other benign | 1 (6.6) | 5 (8.9) | – | |
| Mean pathologic size, cm (range) | 5.2 (3.6–8.1) | 2.1 (0.8–4.2) | <0.001 | |
| PSM, No. (%) | 0 (0) | 3 (5.3) | 0.360 | |
| RCC patients | ||||
| Subtype, No. (%) | Clear cell | 5 (50) | 25 (61.0) | 0.366 |
| Papillary | 4 (40) | 8 (19.5) | – | |
| Chromophobe | 1 (10) | 8 (19.5) | – | |
| Fuhrman grade, No. (%) | 1 | 0 (0) | 5 (15.6) | 0.267 |
| 2 | 4 (44.4) | 17 (53.1) | – | |
| 3 | 5 (55.5) | 10 (31.3) | – | |
| 4 | 0 (0) | 0 (0) | – | |
| Pathologic stage, No. (%) | pT1a | 2 (20) | 37 (90.2) | <0.001 |
| pT1b | 7 (70) | 0 (0) | – | |
| pT2 | 0 (0) | 0 (0) | – | |
| pT3a | 1 (10) | 4 (9.8) | – | |
| Mean pathologic size, cm (range) | 5.2 (3.6–8.1) | 2.1 (0.8–4.2) | <0.001 | |
| PSM, No. (%) | 0 (0) | 1 (2.4) | 0.601 | |
RCC = renal cell carcinoma; AML = angiomyolipoma; PSM = positive surgical margins.
4. Discussion
PN has demonstrated equivalent cancer control to RN for small renal masses [1], and [2], with improved long-term clinical, functional, and survival outcomes over RN [17], [18], [19], [20], and [21]. LPN, which was introduced in 1993 [22], and [23], has emerged as a viable alternative for the surgical management of small renal masses, with oncologic and functional outcomes similar to OPN [4], [24], and [25]. However, LPN is technically challenging, requiring advanced skills to perform precise tumor excision and intracorporeal sutured reconstruction while minimizing ischemia times. Large tumors may present additional technical challenges during PN that may add to the challenges of LPN. Robotic assistance may help overcome technical challenges of LPN, including tumor resection and renal reconstruction under warm ischemia. A number of studies have demonstrated the feasibility of RPN [7], [8], [9], [10], [13], [26], and [27].
PN for tumors >4 cm has been described with satisfactory results with an open approach [3], [4], [5], [6], [7], [8], and [9], and limited reports from experienced surgeons have demonstrated feasibility with a laparoscopic approach [5], and [6]. Our study is the first to evaluate RPN with a specific focus on patients with tumors >4 cm and to compare outcomes with RPN for tumors ≤4 cm.
Rais-Bahrami et al. [5] compared results of LPN for patients with tumors >4 cm (34 patients) and ≤4 cm (274 patients). There were no differences in preoperative characteristics or intraoperative outcomes between groups. Patients with larger tumors had more complications (32.3 vs 25.1%, p = 0.039) and longer hospital stays (4.1 vs 3 d; p = 0.026). Simmons et al. [6] compared results of LPN for patients with tumors >4 cm (58 patients) to 2–4 cm (278 patients) and <2 cm (89 patients). There were no differences between groups in operative time, EBL, and hospital stay. Patients with larger tumors were more likely to require pelvicalyceal repair and had a longer warm ischemia times (38 vs 32 and 30 min; p = 0.002), but there was no difference in complications between groups.
In our study, patients undergoing RPN for renal masses >4 cm had similar demographic and preoperative characteristics to patients undergoing RPN for smaller renal masses. Both groups had similar intraoperative outcomes. There was a trend toward greater blood loss for larger tumors, although this did not reach statistical significance. Similar to Simmons et al. [6], warm ischemia times in our study were longer for larger tumors (25 vs 20 min; p = 0.011), and we did not find a significant difference in complications based on tumor size.
Postoperative variables in this study were similar between groups. There was a trend toward a higher postoperative complication rate for tumors >4 cm (26.6% vs 8.9%), although this difference did not achieve statistical significance, likely because of the smaller number of patients in the large tumor group. Our postoperative complication rate of 26.6% for tumors >4 cm is similar to laparoscopic reports of 24% and 37% [5], and [6]. Two delayed urine leaks occurred in group 1 in which extensive collecting system repair was performed without preplacement of a ureteral catheter and prior to the adoption of the sliding Hem-o-lok clip technique. Patients with larger tumors had a relatively greater decline in mean estimated GFR in the short term. Possible explanations include a larger amount of tissue resected, longer warm ischemia times, and more parenchymal suturing required to complete the renorrhaphy and achieve hemostasis.
Limitations of our study include the retrospective nature our analysis, small sample size, and single-surgeon experience. However, inclusion of different surgeons with varying experience levels may actually confound a comparison of outcomes based on tumor size because of the technical challenges of LPN for tumors >4 cm. Surgeon experience may influence choice of treatment of RCC, even as much as tumor size, demographic characteristics, or medical health [21]. The power of our study to detect a difference between groups is limited by the smaller number of patients with tumors >4 cm. Only early oncologic and functional outcomes are available at this time, and further studies with longer follow-up are needed. Our warm ischemia times were shorter than in comparable laparoscopic series of patients with tumors >4 cm, but a potential criticism is that our total operative times were longer. The most important component of the operative time is the warm ischemia time, as this factor affects subsequent renal function. We feel that the investment of additional time for preparation to save even a few minutes of warm ischemia is time well spent. Also, we are a training program with residents and fellows who regularly perform off-clamp preparatory steps under close guidance. In addition, we treat many patients with obesity (51%), morbid obesity (11%), and prior abdominal surgery (24%), all of which likely increased our overall operative times.
Another potential criticism is that there are experienced laparoscopic surgeons who do not need to rely on robotic technology to safely and efficiently perform LPN for cT1b tumors. We acknowledge that there are highly skilled surgeons capable of performing LPN with great efficiency, even for clinical T1b tumors [5], and [6]. However, a recent report showed that even among surgeons with fellowship training in LPN, RPN is associated with significant improvements in operative parameters, including warm ischemia time [28]. Although most masses treated in that particular study were clinical stage T1a tumors, we feel that the purported benefits of robotic assistance can also extend to the technical challenges of LPN for clinical stage T1b renal tumors.
5. Conclusions
In our initial experience, RPN for renal tumors >4 cm is safe and feasible, showing comparable outcomes to RPN for smaller tumors, although with longer warm ischemia times. We do not necessarily advocate robotic assistance for all patients with renal masses, but it may allow select patients with larger tumors to achieve the convalescence benefits of a minimally invasive approach. Future studies with extended follow-up are necessary to determine the viability of RPN for large tumors as an effective form of treatment.
Author contributions: Craig G. Rogers had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis
Study concept and design: Patel, Siddiqui, Bhandari.
Acquisition of data: Laungani, Shrivastava, Siddiqui.
Analysis and interpretation of data: Patel, Krane.
Drafting of the manuscript: Patel.
Critical revision of the manuscript for important intellectual content: Rogers, Menon.
Statistical analysis: Patel, Rogers.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Rogers, Menon.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: Craig Rogers is a speaker for Intuitive Surgical.
Funding/Support and role of the sponsor: None.
References
- [1] A.F. Fergany, K.S. Hafez, A.C. Novick. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol 163 (2000) (442 - 445)
- [2] R.G. Uzzo, A.C. Novick. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 166 (2001) (6 - 18)
- [3] B.C. Leibovich, M.L. Blute, J.C. Cheville, et al.. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 171 (2004) (1066 - 1070) Crossref.
- [4] M. Marszalek, H. Meixl, M. Polajnar, M. Rauchenwald, K. Jeschke, S. Madersbacher. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. Eur Urol 55 (2009) (1171 - 1178) Abstract, Full-text, PDF, Crossref.
- [5] S. Rais-Bahrami, F.R. Romero, G.C. Lima, et al.. Elective laparoscopic partial nephrectomy in patients with tumors >4 cm. Urology 72 (2008) (580 - 583) Crossref.
- [6] M.N. Simmons, B.I. Chung, I.S. Gill. Perioperative efficacy of laparoscopic partial nephrectomy for tumors larger than 4 cm. Eur Urol 55 (2009) (199 - 208) Abstract, Full-text, PDF, Crossref.
- [7] C.G. Rogers, M. Menon, E.S. Weise, et al.. Robotic partial nephrectomy: a multi-institutional analysis. J Robotic Surg 2 (2008) (141 - 143) Crossref.
- [8] A.J. Wang, S.B. Bhayani. Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal cell carcinoma: single-surgeon analysis of >100 consecutive procedures. Urology 73 (2009) (306 - 310) Crossref.
- [9] M.T. Gettman, M.L. Blute, G.K. Chow, et al.. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with da Vinci robotic system. Urology 64 (2004) (914 - 918) Crossref.
- [10] R.P. Caruso, C.K. Phillips, E. Kau, S.S. Taneja, M.D. Stifelman. Robot assisted laparoscopic partial nephrectomy: initial experience. J Urol 176 (2006) (36 - 39) Crossref.
- [11] M.N. Patel, M. Bhandari, M. Menon, C.G. Rogers. Robotic-assisted partial nephrectomy. BJU Int 103 (2009) (1296 - 1311) Crossref.
- [12] K.K. Badani, F. Muhletaler, M. Fumo, et al.. Optimizing robotic renal surgery: the lateral camera port placement technique and current results. J Endourol 22 (2008) (507 - 510) Crossref.
- [13] S. Kaul, R. Laungani, R. Sarle, et al.. Da Vinci-assisted robotic partial nephrectomy: technique and results at a mean of 15 months of follow-up. Eur Urol 51 (2007) (186 - 192) discussion 191–2 Abstract, Full-text, PDF, Crossref.
- [14] B.M. Benway, A.J. Wang, J.M. Cabello, S.B. Bhayani. Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes. Eur Urol 55 (2009) (592 - 599) Abstract, Full-text, PDF, Crossref.
- [15] D. Dindo, N. Demartines, P.A. Clavien. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240 (2004) (205 - 213) Crossref.
- [16] A.S. Levey, J.P. Bosch, J.B. Lewis, et al.. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 130 (1999) (461 - 470)
- [17] A.S. Go, G.M. Chertow, D. Fan, C.E. McCulloch, C.Y. Hsu. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 351 (2004) (1296 - 1305) Crossref.
- [18] W.C. Huang, A.S. Levey, A.M. Serio, et al.. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 7 (2006) (735 - 740) Crossref.
- [19] R.H. Thompson, S.A. Boorjian, C.M. Lohse, et al.. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy. J Urol 179 (2008) (468 - 471) discussion 472–3
- [20] L. Zini, P. Perrotte, U. Capitanio, et al.. Radical versus partial nephrectomy: effect on overall and noncancer mortality. Cancer 115 (2009) (1465 - 1471) Crossref.
- [21] D.C. Miller, M. Schonlau, M.S. Litwin, J. Lai, C.S. Saigal. Renal and cardiovascular morbidity after partial or radical nephrectomy. Cancer 112 (2008) (511 - 520) Crossref.
- [22] E.M. McDougall, R.V. Clayman, P.S. Chandhoke, et al.. Laparoscopic partial nephrectomy in the pig model. J Urol 149 (1993) (1633 - 1636)
- [23] H.N. Winfield, J.F. Donovan, G.O. Lund, et al.. Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach. J Urol 153 (1995) (1409 - 1414)
- [24] B.R. Lane, I.S. Gill. 5-year outcomes of laparoscopic partial nephrectomy. J Urol 177 (2007) (70 - 74) discussion 74 Crossref.
- [25] M.E. Allaf, S.B. Bhayani, C. Rogers, et al.. Laparoscopic partial nephrectomy: evaluation of long-term oncological outcome. J Urol 172 (2004) (871 - 873) Crossref.
- [26] C.G. Rogers, A. Metwalli, A.M. Blatt, et al.. Robotic partial nephrectomy for renal hilar tumors: a multi-institutional analysis. J Urol 180 (2008) (2353 - 2356) discussion 2356 Crossref.
- [27] B.M. Benway, S.B. Bhayani, C.G. Rogers, et al.. Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional comparison of over 200 procedures. J Urol 182 (2009) (866 - 873) Crossref.
Footnotes
Henry Ford Hospital, Vattikuti Urology Institute, Detroit, Michigan, USA
Corresponding author. Henry Ford Hospital, Vattikuti Urology Institute, 2799 West Grand Blvd, Detroit, MI 48202-2689, USA. Tel. +313 916 2641; Fax: +313 916 4352.
Contents
Copyright © 