Robot‐assisted vs traditional laparoscopic partial nephrectomy: the time for meta‐analysis has not yet arrived

摘要

International guidelines recommend partial nephrectomy (PN) in all cT1 cases, whenever technically feasible. Regardless of the approach used, PN must be finalized to achieve the complete removal of the tumour, whilst preserving the largest possible part of healthy renal parenchyma and avoiding major early and/or late complications. Obviously, the feasibility of PN can be influenced by tumour-, patient- and surgeon-related factors; anatomical and topographical tumour characteristics , as well as patient comorbidities and body mass index, should be carefully considered so as to identify the cases suitable for PN. In addition, the most important factor in the decision-making process can be the surgeon's experience with a specific approach and/or technique . For many years open surgery represented the ‘gold standard’ approach for PN and it is possible that the majority of surgeons remain more confident in treating more complex tumours using this classic approach; however, open surgery requires a non-aesthetic skin incision and painful access through the muscular plane and also entails a long hospital stay and postoperative recovery time. In addition, the risks of chronic pain, herniation or muscle relaxation at the level of the lumbar or abdominal region are underestimated problems that can limit patient satisfaction after this approach. In recent years, traditional laparoscopic PN (LPN) and robot-assisted laparoscopic PN (RAPN) have been recommended as these techniques minimize the invasiveness of open surgery, offering patients better cosmetic results, less postoperative pain, and shorter hospital stay and postoperative recovery time. To date, LPN has been considered to be a challenging procedure requiring a high volume of cases to complete the steep learning curve in an acceptable time and to achieve the optimum level of skills required. Instruments with a limited degree-of-freedom make it technically difficult to follow favourable angles for tumour excision, haemostasis, repair of the collecting system and reconstruction of the parenchymal defect. The consequence was the limited diffusion of this technique into the hands of few very expert surgeons able to apply the procedure for the treatment of more complex cases. The majority of other surgeons continued to prefer the open approach, eventually limiting the laparoscopic approach to technically simpler cases. Robot-assisted PN seems to be a promising procedure, able to bridge the technical difficulties of LPN and leading to a broader diffusion of the laparoscopic treatment of renal masses. Three-dimensional (3D) vision, optical magnification and the patented EndoWrist instruments (Intuitive Surgical, Sunnyvale, CA, USA) allow surgeons to achieve very precise tumour resection and to simplify the reconstructive steps of the procedure, minimizing warm ischaemia time (WIT) and potential damage to the kidney parenchyma even in more complex tumours. Recently, several single- and multicentre, observational, non-comparative series have reported good perioperative (WIT, operating time and perioperative complications), functional (renal function preservation) and early oncological (positive surgical margin rate) outcomes, which support the use of this approach instead of LPN and as the principal alternative to open PN 1. The main factor limiting the further diffusion of RAPN, especially in Europe, is now the availability of the da Vinci robot and its relative costs. Obviously, the available observational, non-comparative studies with limited follow-up cannot confer to RAPN a high level of evidence but, recently, some meta-analyses of available studies comparing LPN and RAPN have been published 2, 3. After a systematic review of the literature, Aboumarzouk et al. 2 performed a meta-analysis of seven comparative studies and concluded that RAPN appears to be a feasible and safe alternative to its laparoscopic counterpart with decreased WIT. In the current issue of the BJUI, Froghi et al. 3