Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study
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ORIGINAL ARTICLE
Robotic‑assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the “Trifecta and Pentafecta” D Sri1 · R. Thakkar1 · H R H Patel1 · J. Lazarus1 · F. Berger1 · R. McArthur1 · H. Lavigueur‑Blouin1 · M. Afshar1 · C. Fraser‑Taylor1 · P. Le Roux1 · J. Liban1 · C. J. Anderson1 Received: 5 May 2020 / Accepted: 17 August 2020 © The Author(s) 2020
Abstract Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if “Trifecta” and “Pentafecta” outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008–2019) was analysed. “Pentafecta” was defined as achievement of “Trifecta” (negative surgical margin, no postoperative complications and WIT of 50% Exophytic Bleeding Infection (chest, woung, urine) Ileus Urine leak Median length of stay
No.
%/(range)
16 10 2 1 2 1 74 15 14 19 12 4 4 days
7%
33% 20% 19% 26% 16% 5% (1–35 days)
Table 5 Pathology outcome No. Histology Benign Oncocytoma AML Malignant Clear Cell RCC Papillary RCC Grade Fuhrman G1-G2 Fuhrman G3-G4 T Stage pT1a pT1b pT3a Positive surgical margin
%/(range)
50 27 13 174 119 31
22% 54% 26% 78% 68% 18%
118 43
68% 32%
144 17 10 2
83% 10% 7% 1%
Table 6 Oncological/functional outcome
Median follow-up Recurrence Deaths All causes Due to RCC Trifecta achievement Pentafecta achievement
No.
%/(range)
25 Months 1
(2–95 months) 0.50%
4 0 145 122
2% 64% 54%
a single case of recurrence in that time (Table 6), giving an overall recurrence rate of 0.3%. There were no deaths attributable to renal malignancy in our series (outcomes
13
determined by death certification). Our cancer-free survival at 1 year was 99% and at 5 years was 97% (Fig. 1). Twenty-seven patients (11%) had an upstage in their CKD status at 12 months post-op. We achieved a trifecta outcome in 67% of cases and a pentafecta outcome in 56% of cases. Multivariate analysis of our series demonstrated no significant determinants of not being able to achieve a trifecta outcome, with age the only predictor of failing to achieve a pentafecta outcome (Table 7).
Discussion We present our decade long experience with RAPN at a tertiary referral centre in the UK, in achieving both good oncological and functional outcomes for our patients. Our PSM rate was
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