Is Robot-assisted Surgery Contraindicated in the Case of Partial Nephrectomy for Complex Tumours or Relevant Comorbidities? A Comparative Analysis of Morbidity, Renal Function, and Oncologic Outcomes

Background: Available comparisons between open partial nephrectomy (OPN) and robot-assisted partial nephrectomy (RAPN) are scarce, incomplete, and affected by non-negligible risk of bias. Objective: To compare RAPN and OPN. Design, setting, and participants: This was an observational study of 472 patients diagnosed with a cT1-2cN0cM0 renal mass and treated with RAPN or OPN assessed in two prospective institutional databases. Outcome measurements and statistical analysis: The study outcomes were morbidity, complications, warm ischaemia time, renal function, positive surgical margins, and oncologic outcomes. Propensity score matching for age at diagnosis, gender, Charlson comorbidity index, preoperative estimated glomerular filtration rate (eGFR), single kidney status, tumour size and side, total PADUA score, any individual PADUA score item, and year of surgery was used to account for baseline confounders. The effect of surgical approach was estimated using linear and logistic regressions for continuous and categorical outcomes. An interaction test was used for subgroup analyses. Results and limitations: Relative to OPN, RAPN was associated with lower rates for overall (21% vs 36%; p<0.0001) and major (3% vs 9%; p=0.03) complications. This benefit was consistent in patients with high PADUA scores, high CCI, large tumours, and low preoperative eGFR (all p>0.05, interaction test). No difference between the groups was observed for warm ischaemia time, postoperative and 1-yr eGFR, and positive surgical margins (all p>0.05). After median follow-up of 41 mo, there was no difference between the groups for the 5-yr rates of local recurrence-free, systemic progression-free, and disease-free survival (all p>0.05). Conclusions: RAPN is associated with overall better perioperative morbidity and lower rates of complications, regardless of characteristics such as tumour complexity and patient comorbidity status. Functional and oncologic outcomes are equal after RARP and OPN. Patient summary: Robot-assisted partial nephrectomy is associated with a better morbidity profile than open partial nephrectomy (OPN) and provides the same cancer control and renal function preservation observed after OPN. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.