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Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis - Beyond the Abstract

This paper presents our first experience with selective suturing or sutureless robot-assisted partial nephrectomy (RAPN). In this study we showed the feasibility and safety of this technique, is associated with intraoperative and postoperative complication rates in line with reports presented in the literature,1–3 a shorter operative time and promising results for the trifecta and functional outcomes.


This technique is part of a comprehensive surgical approach, that encompasses the use of CT and 3D CT preoperative planning, the intraoperative use of ultrasound and ICG, and the surgical principle of only dissecting what needs to be dissected in order to minimize tissue dissection.

Working with 5mmHg intrabdominal pneumoperitoneum pressure during the entire procedure, made possible by the use of the AirSeal system,4,5 not using drain6,7 and the application of the ERAS principles in all our patients, complete the full picture of a low-impact surgical procedure approach, that allows us to achieve a faster peri- and post-operative recovery period.

There is still the need to perform prospective randomized trials that validate the impact of this selective suturing or sutureless technique on long-term functional outcomes, although randomization might present as a difficult step since we should never forget the imperative ethical principle of performing a safe surgical procedure.8,9

We can evaluate preoperatively which patients might be suitable for this technique, but we are only able to confirm its use when the tumoral bed has no active bleeding as evidenced at the end of the procedure, independently of the characteristics of the tumor, because the primary goal is not to put the life of the patient in danger.

We need to take into account that in order to perform this complex surgery and obtain good functional and oncological results, surgical-related human factors are important and include proper surgical training,10–13 preoperative surgical planning,14 intraoperative evaluation, post-operative follow-up, and proper surgeon performance feedback system.15,16

Written by: Rui Farinha1,2,3,4 * Giuseppe Rosiello6,7 Stefano Puliatti1,2,5 Alexandre Mottrie1,2

  1. ORSI Academy, Melle, Belgium
  2. Department of Urology, OLV, Aalst, Belgium
  3. Urology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
  4. Urology Department, Lusíadas Hospital, Lisbon, Portugal
  5. Department of Urology, University of Modena and Reggio Emilia, Modena, Italy
  6. Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
  7. Vita-Salute San Raffaele University, Milan, Italy


References:

  1. Cacciamani GE, Tafuri A, Iwata A, Iwata T, Medina L, Gill K, et al. Quality Assessment of Intraoperative Adverse Event Reporting During 29 227 Robotic Partial Nephrectomies: A Systematic Review and Cumulative Analysis. Eur Urol Oncol 2020;3:780–3. https://doi.org/10.1016/j.euo.2020.04.003.
  2. Buffi NM, Saita A, Lughezzani G, Porter J, Dell’Oglio P, Amparore D, et al. Robot-assisted Partial Nephrectomy for Complex (PADUA Score ≥10) Tumors: Techniques and Results from a Multicenter Experience at Four High-volume Centers. Eur Urol 2020;77:95–100. https://doi.org/10.1016/j.eururo.2019.03.006.
  3. Harke NN, Darr C, Radtke JP, von Ostau N, Schiefelbein F, Eraky A, et al. Retroperitoneal Versus Transperitoneal Robotic Partial Nephrectomy: A Multicenter Matched-pair Analysis. Eur Urol Focus 2020. https://doi.org/10.1016/j.euf.2020.08.012.
  4. Annino F, Topazio L, Autieri D, Verdacchi T, De Angelis M, Asimakopoulos AD. Robotic partial nephrectomy performed with Airseal versus a standard CO2 pressure pneumoperitoneum insufflator: a prospective comparative study. Surg Endosc 2017;31:1583–90. https://doi.org/10.1007/s00464-016-5144-y.
  5. La Falce S, Novara G, Gandaglia G, Umari P, De Naeyer G, D’Hondt F, et al. Low Pressure Robot-assisted Radical Prostatectomy With the AirSeal System at OLV Hospital: Results From a Prospective Study. Clin Genitourin Cancer 2017;15:e1029–37. https://doi.org/10.1016/j.clgc.2017.05.027.
  6. Peyronnet B, Pradère B, De La Taille A, Bruyère F, Doumerc N, Droupy S, et al. Postoperative drainage does not prevent complications after robotic partial nephrectomy. World J Urol 2016;34:933–8. https://doi.org/10.1007/s00345-015-1721-2.
  7. Abaza R, Prall D. Drain placement can be safely omitted after the majority of robotic partial nephrectomies. J Urol 2013;189:823–7. https://doi.org/10.1016/j.juro.2012.08.236.
  8. Lim C-Y, In J. Randomization in clinical studies. Korean J Anesthesiol 2019;72:221–32. https://doi.org/10.4097/kja.19049.
  9. Palmer CR, Rosenberger WF. Ethics and practice: alternative designs for phase III randomized clinical trials. Control Clin Trials 1999;20:172–86. https://doi.org/10.1016/s0197-2456(98)00056-7.
  10. Puliatti S, Mazzone E, Dell’Oglio P. Training in robot-assisted surgery. Curr Opin Urol 2020;30:65–72. https://doi.org/10.1097/MOU.0000000000000687.
  11. Mazzone E, Puliatti S, Amato M, Bunting B, Rocco B, Montorsi F, et al. A Systematic Review and Meta-Analysis on the Impact of Proficiency-Based Progression Simulation Training on Performance Outcomes. Ann Surg 2020. https://doi.org/10.1097/SLA.0000000000004650.
  12. Volpe A, Ahmed K, Dasgupta P, Ficarra V, Novara G, van der Poel H, et al. Pilot Validation Study of the European Association of Urology Robotic Training Curriculum. Eur Urol 2015;68:292–9. https://doi.org/10.1016/j.eururo.2014.10.025.
  13. Larcher A, De Naeyer G, Turri F, Dell’Oglio P, Capitanio U, Collins JW, et al. The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation. Eur Urol 2019;75:1023–31. https://doi.org/10.1016/j.eururo.2019.02.031.
  14. Klatte T, Ficarra V, Gratzke C, Kaouk J, Kutikov A, Macchi V, et al. A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy. Eur Urol 2015;68:980–92. https://doi.org/10.1016/j.eururo.2015.04.010.
  15. Marconi L, Desai MM, Ficarra V, Porpiglia F, Van Poppel H. Renal Preservation and Partial Nephrectomy: Patient and Surgical Factors. Eur Urol Focus 2016;2:589–600. https://doi.org/10.1016/j.euf.2017.02.012.
  16. Vickers AJ, Sjoberg D, Basch E, Sculli F, Shouery M, Laudone V, et al. How do you know if you are any good? A surgeon performance feedback system for the outcomes of radical prostatectomy. Eur Urol 2012;61:284–9. https://doi.org/10.1016/j.eururo.2011.10.039.


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