EAU 2019: Minimally-Invasive Partial Nephrectomy: An Operation Without Limits?

Barcelona, Spain (UroToday.com) In this session, Dr. Mottrie argued in favor of the growth of robotic-assisted partial nephrectomy. He started the talk by reviewing past data: colorectal and hernia surgery have a complication rate of 37% and 17%, respectively. In the United States, approximately 170 billion dollars are spent annually on surgery, with approximately 41 billion spent on readmissions.   Given high complication rates and the significant costs associated with readmissions, Dr. Mottrie feels that we must progress as a group. Improving outcomes can be with better education and proficiency-based training, and to expand surgical innovations.

Starting with education, Dr. Mottrie stated this can fall in three categories: standardization of training, improvement of education and quality assured training, and licensing. For example, at Dr. Mottrie’s center, a robotic curriculum was initiated which has now been in practice for greater than 5 years and involves 10 institutions. The importance of a structured training robotic partial nephrectomy program is essential to improve patient outcomes during the surgeon’s learning curve. In a 2018 European Urology study, no differences in complications, positive margin rate, and post-op renal function were seen in curriculum and standard of care robotic partial nephrectomy.

Furthermore, since urologic guidelines do not recommend a specific approach for partial nephrectomy, surgeons still debate wedge resection versus enuceoresection versus pure enucleation. A large systematic review meta-analysis published in the Journal of Urology in 2018 demonstrated equivalent outcomes for robotic partial nephrectomy compared to open partial nephrectomy. Additionally, two studies support the notion that robotic-assisted surgery was associated with lower excisional renal volume loss compared to open surgery. In studies evaluating surgical experience, approximately 20 cases are needed to hit a warm ischemia time of fewer than 20 minutes and 150 cases are needed to hit a goal of 13-14 minutes.

Robotic partial nephrectomy has been increasing in popularity, with over 160 publications in 2016. There is support for the utilization of robotic partial nephrectomy for complex, larger masses in the future, as data supports its use in select cT2 masses with acceptable perioperative outcomes.

Dr. Mottrie briefly reviewed newer (and expensive) technologies to improve preoperative and intraoperative planning, including 3-D reconstruction with a TilePro onlay, 3-D printed models, intraoperative ultrasound, and fluorescence. Additionally, enhanced recovery after surgery may be possible with the use of low pressure laparoscopic procedures, creating less microvascular ischemia and CO2 reabsorption.

In summary, Dr. Mottrie believes that robotic-assisted partial nephrectomy is an operation without limits in the appropriately trained individual. The goals include providing patients with fewer complications and excellent oncological outcomes. The operation will likely take over for most indications for nephron-sparing surgery and can be used on more complex cases in the future.

Presented by: Alexandre Mottrie, MD, PhD, Department of Urology, OLV Aalst, Belgium

Written by: David B. Cahn, DO, MBS @dbcahn Fox Chase Cancer Center at the 34th European Association of Urology (EAU 2019) #EAU19, conference in Barcelona, Spain from March 15-19, 2019.