Introduction

We assessed the feasibility of robot-assisted partial nephrectomy (RAPN) in a contemporary series of patients with highly-complex tumors (PADUA score≥ 10) treated at three high-volume robotic surgery institutions.

Methods

Data from a multi-institutional database on patients subjected to RAPN for clinically-localized kidney cancer between 2010 and 2016 were reviewed. Overall, 198 patients with highly-complex renal tumors, defined as a PADUA score≥ 10, were included. Complications, functional and oncological outcomes were assessed. Optimal surgical outcomes, defined according to the Margin Ischemia and Complications (MIC) binary system (absence of Clavien-Dindo >2 complications, warm ischemia time [WIT] <20 minutes and absence of positive surgical margins) were assessed. Finally, predictors of optimal surgical outcomes were determined using logistic regression models (LRMs).

Results

Median patient age was 61.5 years (IQR: 53-68), median preoperative tumor size was 43 mm (IQR 28-54), and median preoperative creatinine was 0.92 mg/dL (IQR: 0.80-1.13). Overall, 91 (46.0%) patients had a PADUA score 10, followed by 65 (32.8%) with a score of 11, 33 (16.7%) with a score of 12 and 9 (4.5%) with a score of 13. Median operative time was 180 minutes (IQR: 131-221), median WIT was 18 minutes (IQR: 15-22), and median estimated blood loss was 150 ml (IQR: 100-300). WIT was > 20 minutes in 62 (31.3%) patients, while a Clavien-Dindo >2 complication and positive surgical margins were observed in 12 patients (5.0%) and 4 (2.0%) individuals, respectively. Optimal surgical outcomes were achieved in 126 (63.6%) patients. Median creatinine the day after surgery was 1.10 mg/dL and remained stable 2 weeks later (median: 1.10 mg/dL. At a median follow-up of 22 months, no local or distant recurrence of the disease was observed. In multivariable LRMs, after adjustment for patient age, gender, BMI, side, CCI, and tumor size, extremely complex tumors (PADUA score 12-13) were associated with a 2.7 -fold higher risk of not achieving optimal outcomes (OR: 1.03-7.02; p=0.044). In addition, males showed a 2.31-fold higher risk of not achieving optimal surgical outcomes (95%CI: 1.04-5.14; p=0.040) relative to their female counterparts.

Conclusions

In experienced hands, RAPN can be considered as an effective treatment option even for complex renal lesions. Increasing tumor complexity may affect the surgical outcomes even in this highly-selected patient population.

Funding

None