Transitioning to robotic partial nephrectomy with a team-based proctorship achieves the desired improved outcomes over open and laparoscopic partial nephrectomy

Abstract

Proctoring may facilitate a safe transition to robotic-assisted partial nephrectomy (RAPN) for centres performing open (OPN) and laparoscopic partial nephrectomies (LPN). This study compared the 5-year outcomes of RAPN, initiated with a team-based proctorship, with OPN and LPN. Following an observation course at the proctor’s institution and a 3-surgeon performance of proctored RAPN in August 2014, a review of 90 RAPN, 29 LPN and 43 OPN consecutively performed by the same team from 2013 to 2019 at National University Hospital, Singapore was conducted. Peri-operative data, functional and oncological outcomes were compared amongst the three groups. Most cases were performed robotically after 2015 with comparable baseline characteristics in all groups. Median RENAL Nephrometry Score was not significantly different between RAPN (8 [IQR 6, 9]) and OPN (9 [IQR 7, 10]) (P = 0.12) but was significantly lower for LPN (7 [IQR 5, 8]) compared to RAPN (P = 0.002). RAPN achieved the lowest blood loss (226 ml vs.348 ml and 263 ml for OPN and LPN respectively, P = 0.02), transfusion rate (3% vs.21% and 17% respectively, P = 0.003) and median length of stay after surgery (4 vs.6 and 5 days respectively, P = 0.001). Complication rates, warm ischemic times were similar between the three approaches with no differences in 1-year and long-term renal function. The rate of positive surgical margin was 8%, 8% and 3% for RAPN, LPN and OPN, respectively (P = 0.76), with a single recurrence in each arm. Despite modest hospital volume, a team-based proctorship facilitated the transition to the Da Vinci robotic platform to perform partial nephrectomies of equivalent complexities as open surgery, achieving improved perioperative outcomes, while maintaining oncological and kidney functional results.