Surgical quality, cancer control and functional preservation: Introducing a novel trifecta for robot-assisted partial nephrectomy

Background: In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes. Methods: A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival. Results: Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation. Conclusions: This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality

Surgical quality, cancer control and functional preservation: Introducing a novel trifecta for robot-assisted partial nephrectomy

BACKGROUND: In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes.METHODS: A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo >= 3 complications and <= 30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage >= IIIa, recurrence-free and overall survival.RESULTS: Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation.CONCLUSIONS: This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality

Off-clamp versus on-clamp robot-assisted partial nephrectomy: A propensity-matched analysis

Introduction & Objectives: To compare perioperative and functional outcomes following off and on-clamp robot-assisted partial nephrectomy (RAPN). Materials & Methods: This study used prospective multinational collaborative Vattikuti Collective Quality Initiative (VCQI) database for RAPN. The primary objective of this study was comparison of perioperative and functional outcomes between patients who underwent off-clamp and on-clamp RAPN. Propensity scores were calculated for age, sex, BMI, renal nephrometery score (RNS) and preoperative estimated glomerular function rate (eGFR). Results: Of the 2,114 patients, 210 had undergone off-clamp RAPN and others on-clamp. Two groups were not comparable at baseline with different ages, tumors, and renal nephrometery scores before matching. Propensity matching was possible for 205 patients in a 1:1 ratio. The two groups were comparable for age, sex, BMI, tumor size, multifocality, tumor side, the face of tumor, RNS, polar location of the tumor, surgical access and preoperative hemoglobin, creatinine and eGFR post matching. There was no difference between two groups for intraoperative (4.8% vs. 5.3%, p=0.823) and postoperative complications (11.2% vs. 8.3%, p=0.318). Need for blood transfusion (2.92% vs. 0, p=0.030) and conversion to radical nephrectomy (10.2% vs. 1%, p\u3c0.0001) were significantly higher in off-clamp group. At the last follow-up, there was no difference between the two groups for creatinine and eGFR. Mean fall in eGFR at last follow-up compared to baseline was comparable between the two groups (-16.03 ml/min vs. -17.3 ml/min, p=0.985). Conclusions: Off-clamp RAPN doesn\u27t result in better renal functional preservation, albeit its associated with increased rates of conversion to radical nephrectomy and blood transfusion