Objective: To compare the outcomes of robotic radical nephrectomy (RRN) to those of laparoscopic radical nephrectomy (LRN) for large renal masses. Methods: This was a retrospective analysis of RRN and LRN cases performed for large (≥ cT2) renal masses from 2004 to 2017 and collected in the multi-institutional international database (ROSULA: RObotic SUrgery for LArge renal masses). Peri-operative, functional, and oncologic outcomes were compared between each approach. Descriptive analyses were performed and presented as medians with interquartile ranges. Inverse probability of treatment weighting-adjusted multivariable analyses were used to identify predictors of peri-operative complications. Kaplan–Meier analysis and Cox regression models were used to assess survival outcomes. Results: A total of 941 patients (RRN = 404, LRN = 537) were identified. There was no difference in terms of gender, age, and clinical tumor size. Over the study period, RRN had an annual increase of 11.75% (95% CI [7.34, 17.01] p < 0.001) and LRN had an annual decline of 5.39% (95% CI [−6.94, −3.86] p < 0.001). Patients undergoing RRN had higher BMI (27.6 [IQR 24.8–31.1] vs. 26.5 [24.1–30.0] kg/m2, p < 0.01). Operative duration was longer for RRN (185.0 [150.0–237.2] vs. 126 [90.8–180.0] min, p < 0.001). Length of stay was shorter for RRN (3.0 [2.0–4.0] vs. 5.0 [4.0–7.0] days, p < 0.001). RRN cases presented more advanced disease (higher pathologic staging [pT3–4 52.5 vs. 24.2%, p < 0.001], histologic grade [high grade 49.3 vs. 30.4%, p < 0.001], and rate of nodal disease [pN1 5.4 vs. 1.9%, p < 0.01]). Surgical approach did not represent an independent risk factor for peri-operative complications (OR 1.81 95% CI [0.97–3.39], adjusted p = 0.2). The main study limitation is the retrospective design. Conclusions: This study represents the largest known multi-center comparison between RRN and LRN. The two procedures seem to offer similar peri-operative outcomes. Notably, RRN has been increasingly utilized, especially in the setting of more advanced and surgically challenging disease without increasing the risk of peri-operative complications.
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