Robotic versus Open Partial Nephrectomy: A Systematic Review and Meta-Analysis

<div><p>Objectives</p><p>To critically review the currently available evidence of studies comparing robotic partial nephrectomy (RPN) and open partial nephrectomy (OPN).</p><p>Materials and Methods</p><p>A comprehensive review of the literature from Pubmed, Web of Science and Scopus was performed in October 2013. All relevant studies comparing RPN with OPN were included for further screening. A cumulative meta-analysis of all comparative studies was performed and publication bias was assessed by a funnel plot.</p><p>Results</p><p>Eight studies were included for the analysis, including a total of 3418 patients (757 patients in the robotic group and 2661 patients in the open group). Although RPN procedures had a longer operative time (weighted mean difference [WMD]: 40.89; 95% confidence interval [CI], 14.39–67.40; p = 0.002), patients in this group benefited from a lower perioperative complication rate (19.3% for RPN and 29.5% for OPN; odds ratio [OR]: 0.53; 95%CI, 0.42–0.67; p<0.00001), shorter hospital stay (WMD: −2.78; 95%CI, −3.36 to −1.92; p<0.00001), less estimated blood loss(WMD: −106.83; 95%CI, −176.4 to −37.27; p = 0.003). Transfusions, conversion to radical nephrectomy, ischemia time and estimated GFR change, margin status, and overall cost were comparable between the two techniques. The main limitation of the present meta-analysis is the non-randomization of all included studies.</p><p>Conclusions</p><p>RPN appears to be an efficient alternative to OPN with the advantages of a lower rate of perioperative complications, shorter length of hospital stay and less blood loss. Nevertheless, high quality prospective randomized studies with longer follow-up period are needed to confirm these findings.</p></div

Forest plots of surgical outcomes.

<p>(a) overall complications; (b) postoperative complications divided into Clavien grade 1–2 and 3–4; (c) transfusions; (d) conversions to radical nephrectomy; (e) ischemia time; (f) estimated GFR change; (g) unclamping rate; (h) length of stay; (i) estimated blood loss; (j) operative time; (k) positive margins. The following studies are cited: Alemozaffar et al 2013 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Alemozaffar1" target="_blank">[26]</a>, Laydner et al 2013 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Laydner1" target="_blank">[27]</a>, Lee et al 2011 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Lee1" target="_blank">[10]</a>, Lucas et al 2012 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Lucas1" target="_blank">[28]</a>, Masson-Lecomte et al 2013 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-MassonLecomte1" target="_blank">[11]</a>, Minervini et al 2013 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Minervini1" target="_blank">[12]</a>, Simhan et al 2012 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Simhan1" target="_blank">[13]</a>, Yu et al 2012 <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Yu1" target="_blank">[29]</a>.</p

Flowchart for records selection process of the meta-analysis.

<p>Flowchart for records selection process of the meta-analysis.</p

Characteristics of included studies and quality assessment.

<p>R = retrospective; RP = retrospective analysis, prospective data collecting; PN = prospective non-randomized design; NIS = USA national inpatient sample; NA = not available.</p><p>*Matching: 1 = age; 2 = gender; 3 = body mass index; 4 = American Society of Anesthesiologists score; 5 = tumor laterality; 6 = tumor size; 7 = nephrometry score (RENAL or PADUA); 8 = pre-op eGFR; 9 = single surgeon.</p>#<p>Mean or median.</p>§<p>using modified Newcastle-Uttawa Scale (NOS) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Wells1" target="_blank">[19]</a>, <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0094878#pone.0094878-Fan1" target="_blank">[20]</a>.</p

Patient demographics of robotic versus open partial nephrectomy.

<p>*median.</p

Reporting bias analysis.

<p>Funnel plots of the studies included in this meta-analysis reporting overall complication rates (a) and postoperative complications with Clavien grade classifications (b). SE = standard error; OR = odds ratio.</p

Propensity-score adjusted comparison of surgical outcomes for RPN and OPN.

<p>IQR  =  interquartile range; RPN  =  robotic partial nephrectomy; OPN  =  open partial nephrectomy; OR  =  operative room; EBL  =  estimated blood loss; LOS  =  length of stay; VAPS  =  visual analog pain scale; CKD  =  chronic kidney disease.</p><p>*SURGICEL.</p>#<p>defined as a decreased level of Hb requiring blood transfusion or surgical/endoscopic/radiologic intervention 24 hr after surgery or later.</p>ξ<p>defined as extra-renal urine extravasation that required prolonged maintenance of a drain, re-insertion of a drain, insertion of a ureteral stent or other surgical intervention. All leaks were verified by drain fluid chemical analysis. Cases of urinary leak in both RPN and OPN groups were managed expectantly.</p

Propensity-score adjusted multivariable stepwise logistic regression analysis for surgical outcomes of RPN versus OPN.

<p>RPN  =  robotic partial nephrectomy; OPN  =  open partial nephrectomy; OR  =  operative room; EBL  =  estimated blood loss; LOS  =  length of stay; CKD  =  chronic kidney disease.</p><p>*Models adjusted for age, gender, baseline Charlson comorbidity index, BMI, ASA, and DAP score.</p