Retroperitoneal Single Port vs Transperitoneal Multiport Robot Assisted Partial Nephrectomy (RAPN) in Patients with Highly Hostile Abdomens, a tertiary referral center comparative analysis

doi:10.21203/rs.3.rs-4829943/v1

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Research Article

Retroperitoneal Single Port vs Transperitoneal Multiport Robot Assisted Partial Nephrectomy (RAPN) in Patients with Highly Hostile Abdomens, a tertiary referral center comparative analysis

https://doi.org/10.21203/rs.3.rs-4829943/v1

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Purpose

To explore perioperative and functional outcomes in a cohort of patients with highly hostile abdomens treated with retroperitoneal single port vs transperitoneal multiport robot assisted partial nephrectomy.

Materials and Methods

Clinical and surgical data of all consecutive patients treated with Transperitoneal Multiport and Retroperitoneal Single-Port Robot Assisted Partial Nephrectomy between March 2019 and January 2024 were prospectively collected and retrospectively analyzed. The presence of “hostile abdomen” was defined as personal history of at least one major abdominal surgery. Multivariable logistic regression analysis was used to assess independent predictors of Trifecta achievement.

Results

Overall, clinical and surgical data of 247 consecutive patients were prospectively collected, of these 71 met the inclusions criteria and were retrospectively analyzed. No differences emerged in baseline features. Previous surgery proximity to the site of partial nephrectomy was found comparable among groups (p = 0.21). Retroperitoneal single port group showed a significantly lower operative time (171 vs 235 min, p = 0.02) and estimated blood loss (70 vs 100 cc, p = 0.04) while open conversion was significantly higher (9.3%) in case of multiport treatment (p = 0.001). A significative lower rate of major postoperative complications (7.1 vs 16.3%, p = 0.03) as well as 90-days readmissions (p = 0.04) was found in case of single port retroperitoneal procedures. Adjusting for age, BMI and CCI, retroperitoneal single port approach was confirmed as independent predictor of Trifecta achievement (OR 1.62 CI 1.18–2.35 p = 0.01).

Conclusion

Single port retroperitoneal approach confirmed valuable perioperative outcomes reducing the major complication rate and minimizing the overall surgical impact on patients as compared to the multiport transperitoneal group.

Previous surgery

Robotics

Nephrectomy

Renal cancer

Complications

Dealing with hostile abdomens still represents one of the main surgical challenges in minimally invasive surgery[1]. Particularly, the worldwide spread of minimally invasive Partial Nephrectomy (PN) for localized T1 renal masses and the continuous advancements in robotic surgery, have widened the indications of Robot Assisted Partial Nephrectomy (RAPN) also in patients with personal history of major abdominal surgery[2]. In this setting, the retroperitoneal (RP) surgical access may overcome the limitations of the transperitoneal (TP) one by reducing the risk of adhesions-related intraoperative and perioperative complications as well as shortening the operative time[3]. Given the central role of surgeons preference in the approach-selection, a clear trend emerged in favor of the adoption of the TP over the RP approach, also due to the wider working space required by the Multi-Port (MP) systems [4–5]. The recent introduction of da Vinci single-port (SP) robotic platform (Intuitive Surgical, Sunnyvale, CA) may shift this paradigm. Indeed, the high flexibility of surgical instruments and the narrow space required for triangulation allow to bring the kidney surgery back to the retroperitoneal space possibly avoiding the above-mentioned adhesion-related issues[6]. To date, initial data from both single-center[7–9] and multi-institutional series[10] assessed the feasibility of SP-RAPN in unselected patients showing promising results. Nevertheless, evaluating its benefits and harms in highly complex patients still represent an unmet need. As such, we sought to compare retroperitoneal single port RAPN vs transperitoneal multiport RAPN in terms of perioperative and functional outcomes in a cohort of patients with highly hostile abdomens.

Study population

Surgical data of all consecutive patients treated between March 2019 and January 2024 with RP Single-and TP Multi-Port Robot Assisted Partial Nephrectomy at a single center (UIH, Chicago, Illinois, USA) were prospectively included in a self-maintained database and retrospectively gathered. All patients with localized renal masses amenable to partial nephrectomy were included. Demographic, oncologic and perioperative features were collected by a dedicated clinical software (Epic system®) and assessed. The RENAL nephrometry score [11] was evaluated for each patient basing on the preoperative cross-sectional imaging. Intraoperative and postoperative complications were graded by the Clavien–Dindo classification system [12] while significant renal function loss was defined in case of ΔeGFR (difference between eGFR at 6-month follow-up and baseline) > 25%. The Trifecta achievement was defined accordingly with Kaouk et al.[13] as the presence of negative pathological surgical margins, absence of perioperative complications and warm ischemia time < 25 minutes.

Hostile Abdomen

The presence of “hostile abdomen” was defined as the personal history of at least one major transperitoneal abdominal surgery (a comprehensive report is provided in Supplementary Table 1). Previous surgery was also compared according to its proximity to the site of the partial nephrectomy in two categories (upper contralateral/lower abdominal quadrant or minimally invasive, upper ipsilateral abdominal quadrant or middle line). Only patients with “hostile abdomen” were included in the analysis. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The present research was performed after local ethical commitment approval IRB 20201428. Basing on surgical approach, patients were stratified in two groups (Retroperitoneal SP-RAPN vs Transperitoneal MP-RAPN).

Surgical technique

All transperitoneal MP-RAPN cases were performed at our institution by two surgeons with extensive experience using the standard multiport da Vinci Xi system according to the previously described standard technique [14]. All retroperitoneal SP-RAPN procedures were performed with da Intuitive daVinci SP system® and surgical approach was defined according to the surgeon's preference as previously reported (full flank standard approach vs Low Anterior Access (LAA)[6]).

Statistical analysis

The Statistical analyses were conducted following established guidelines [16]. Descriptive statistics were obtained reporting medians (and interquartile range, IQR) for continuous variables, while frequencies and proportions were used for categorical variables. After testing the normality of variables’ distribution (by the Kolmogorov-Smirnov test), continuous variables were compared by the Mann-Whitney test. We statistically analyzed baseline characteristics and peri- and post-operative outcomes, comparing the TP MP- and the RP SP- RAPN. Multivariable logistic regression analysis was used to test the probability of the Trifecta achievement adjusting for surgical approach, ASA score, CCI and BMI. All statistical analyses were performed using R software (version 4.3.2).

Overall, clinical and surgical data of 247 consecutive patients treated with RAPN at our institution were prospectively collected and retrospectively analyzed. Of these, 87 (35.2%) were treated with retroperitoneal SP-RAPN while 113 (45.7%) underwent transperitoneal MP-RAPN. The presence of complex abdomen was recorded in 28 (32.2%) and 43 (38.1%) cases in the RP SP-RAPN and TP MP-RAPN, respectively. A detailed description of patient previous abdominal surgery is represented in Supplementary Table 1. In terms of baseline features no significant differences were recorded, median age at surgery was 57 (IQR 44–68) and 58 (IQR 48–65) years while median BMI was 30.12 (IQR 26.1–36.6) and 31.30 (IQR 25.1–38.3) kg/m2 in the RP SP-RAPN and TP MP-RAPN, respectively (p = 0.8, p = 0.18). Previous surgery proximity to the site of partial nephrectomy was found comparable among groups (p = 0.21). Although preoperative hypertension was found higher among the SP group (p = 0.04), no differences emerged in overall patient complexity with a median CCI score of 3 (IQR 2–4) and 3 (IQR 2–5) in the RP SP-RAPN and TP MP-RAPN, respectively (p = 0.7) Table 1. As regards tumor features, no significant differences were recoded between groups in terms median RENAL Nephrometry Score (8 [IQR 6–9] vs 7 [IQR 5–8] p = 0.2) as well as clinical T stage (p = 0.9) while a slightly higher although not significant rate of posterior tumors was recorded in the SP group (p = 0.06). Considering intraoperative outcomes, RP SP-RAPN showed a significantly lower operative time (171 min [IQR 104–238] vs 235 min [IQR 160–302)], p = 0.02) and estimated blood loss (70 cc [IQR 40–170)] vs 100 cc [IQR 60–200], p = 0.04), Fig. 1. Open conversion occurred in the 9.3% of patients treated with TP MP-RAPN while no cases were recorded in the RP SP-RAPN group (p = 0.001). In term of hilar clamping no significant differences were found among groups with a slightly higher rate of off-clamp procedures in the MP group (p = 0.07), Table 2. As regards postoperative outcomes, a significantly lower rate of major postoperative complications was found in the RP SP-RAPN group as compared to the TP MP-RAPN (7.1% vs 16.3%, p = 0.03), as well as a significantly lower rate of 90-days readmission (7.1% vs 14.1%, p = 0.04) Supplementary Table 2. In terms of mid-term surgical and functional outcomes, after a median follow up of 16 months (IQR 6–24) no differences were recorded in terms of significant renal function loss (p = 0.9). Adjusting for age, BMI and CCI, RP SP-RAPN was confirmed as independent predictor of Trifecta achievement (OR 1.62 CI 1.18–2.35 p = 0.01), Supplementary Table 3.

Table 1

Comparison of the preoperative characteristics of patients with hostile abdomen treated with transperitoneal multiport or retroperitoneal single port RAPN
Characteristic			Overall, N = 71¹	Multiport Transperitoneal RAPN, N = 43¹	Single Port Retroperitoneal RAPN, N = 28¹	p-value²
Age at Surgery, median (IQR)			58 (48–65)	58 (48–65)	57 (44–68)	0.8
Gender (male), n (%)			47 (66.2)	28 (65.1)	19 (67.9)	0.08
BMI (kg/m2), median (IQR)			30.8 (25.6–37.6)	31.3 (25.1–38.3)	30.1 (26.1–36.6)	0.18
Race, n (%)						0.06
	White		18 (25.4)	11 (25.6%	7 (25)
	Black		18 (25.4)	10 (23.3)	8 (28.6)
	Hispanic		15 (21.1)	9 (20.9)	6 (21.4)
	Chinese		9 (12.6)	5 (11.6)	4 (14.2)
	South-Asia		11 (15.5)	8 (18.6)	3 (10.8)
CCI, median (IQR)			4 (3–5)	4 (3–5)	4 (3–5)	0.7
ASA, median (IQR)			3 (2–4)	3 (2–4)	3 (2–5)	0.7
Hypertension, n (%)			43 (61%)	22 (51%)	21 (75%)	0.04
Diabetes, n (%)			24 (34%)	14 (33%)	10 (36%)	0.8
Antiplatelet or anticoagulant therapy, n (%)			15 (21%)	9 (20.8%)	6 (21%)	> 0.9
Previous surgery location, n (%)
	Upper contralateral, lower abdominal quadrants or minimally invasive, n(%)		45 (63.4)	28 (65.1)	17 (60.7)	0.6
	Upper ipsilateral abdominal quadrant or middle line, n(%)		26 (36.6)	15 (34.9)	11 (39.3)	0.11
Preoperative Hb (g/dL), median (IQR)			12.40 (9.7–15.8)	12.30 (10.1–15.3)	12.80 (9.2–16.7)	0.4
Preoperative serum creatinine (mg/dL), median (IQR)			0.83 (0.71–1.3)	0.71 (0.65–1.1)	0.88 (0.67–1.4)	0.7
Preoperative eGFR (mL/min/1.73m2), median (IQR)			87 (51–90)	84 (49–86)	88 (58–90)	0.4
Clinical tumor size (mm), median (IQR)			2.50 (1.9–3.7)	2.55 (1.7–3.8)	2.50 (1.5–3.6)	0.9
Clinical T stage, n (%)						0.9
		cT1a	61 (85.9)	36 (83.8)	25 (89.2)
		cT1b	10 (14.1)	7 (16.2)	3 (10.8)
Renal Nephrometry score, median (IQR)			7 (5–9)	7 (5–8)	8 (6–9)	0.2
Posterior lesions, n(%)			26 (36.6)	15 (34.9)	11 (39.4)	0.06
¹ Median (IQR); n / N (%)
² Wilcoxon rank sum test; Fisher’s exact test; Pearson’s Chi-squared test

Table 2

Perioperative and pathological outcomes of patients with hostile abdomen treated with transperitoneal multiport or retroperitoneal single port RAPN
Characteristic		Overall, N = 71¹	Multiport Transperitoneal RAPN, N = 43¹	Single Port Retroperitoneal RAPN, N = 28¹	p-value²
Operative time (min), median (IQR)		197 (120–280)	235 (160–302)	171 (104–238)	0.019
EBL (cc), median (IQR)		80 (50–130)	100 (60–200)	70 (40–170)	0.04
Clampless procedures, n (%)		8 (11.3)	5 (11.6)	3 (10.7)	0.11
Ischemia Time (min), median (IQR)		18 (14–22)	18 (14–21)	19 (16–23)	0.09
Open conversion, n (%)		4 (5.6%)	4 (9.3%)	0 (0%)	0.001
Transfusion rate, n(%)		7 (9.8)	5 (11.6)	2 (7.1)	0.08
Hb level at discharge (g/dL), median (IQR)		10.7 (9.7–15.8)	10.4 (9.2–13.1)	11.1 (9.9–14.1)	0.8
Serum creatinine level at discharge (mg/dL), median (IQR)		1.12 (0.71–1.3)	1.10 (0.87–1.32)	1.18 (0.91–1.43)	0.7
eGFR level at discharge (mL/min/1.73m2), median (IQR)		69 (51–90)	71 (46–84)	67(43–82)	0.4
Length of Hospital stay (LOS), median (IQR)		2 (0–3)	3 (2–4)	0 (0–1)	0.001
Opioid use on 0 or 1 PO Day, n (%)		53 (74.0)	33 (76.7)	10 (35.7)	0.001
Narcotic use one week after surgery, n (%)		12 (16.4)	9 (20.9)	3 (10.7)	0.03
Early postoperative complications CD ≥ 3a, n (%)		9 (12.7%)	7 (16.3%)	2 (7.1%)	0.03
90-days readmission rate, n (%)		16 (23)	6 (14.1)	2 (7.1)	0.04
Positive Surgical Margin, n (%)		6 (9.9)	4 (13.9)	2 (7.1)	0.2
Pathological T stage, n (%)		63 (88.7)	40 (93.0)	23 (82.1)	0.9
	pT1a	52 (82.5)	33 (75.0)	19 (82.6)
	pT1b	11 (15.5)	7 (17.5)	4 (17.4)
Significant renal function loss at last follow up ³, n(%)		32 (45)	19 (44)	13 (46)	0.9
Follow-up, median (IQR)		18 (12–24)	20 (14–26)	16 (12–20)	0.06
¹ Median (IQR); n / N (%)
² Wilcoxon rank sum test; Fisher’s exact test; Pearson’s Chi-squared test

During the last decades, minimally invasive nephron sparing surgery further widened its broadens confirming valuable outcomes in managing more complex patient and tumors settings [17–19]. Nevertheless, the presence of intraperitoneal adhesions due to previous major abdominal surgery still represent a non-negligible surgical challenge possibly jeopardizing perioperative safety and prolonging the operative time [4]. Notwithstanding the theoretical advantages provided by the RP approach in these patients, the confined space of work and the less familiar anatomical landmarks still burden on its adoption across the urological community [20]. This factor is also driven by the inherent limitations of multiport robotic systems that have led to a progressive shift of kidney surgery towards the transperitoneal approach [21]. In this scenario, several preliminary series evaluating SP-RAPN outlined a trend reversal with a growing body of surgeons performing RP approach with both full flank and supine patient positioning [7–10]. Nevertheless, the potential benefits of RP SP-RAPN in the complex abdomen patient-setting are still undetermined.

To the best of our knowledge, this represents the first series focused on patients with hostile abdomens comparing perioperative and functional outcomes of transperitoneal MP- vs retroperitoneal SP- RAPN.

First key finding of our research is that RP SP-RAPN significantly reduced the rates of perioperative complications as compared to the transperitoneal MP group, thus increasing the surgical safety in patients with hostile abdomens. This result might be explained by the reduced tissue dissection and the avoidance of adhesiolysis that is usually performed laparoscopically in the first steps of MP procedures, often representing in this setting a technically demanding surgery [22]. Consistently to our results, a large multi-institutional matched series assessing both robot-assisted and laparoscopic TP vs RP PN outlined a significant higher major-complications rate in case of transperitoneal procedures [23]. Conversely, a recent comparative series assessing trans- versus retroperitoneal MP RAPN pointed out no differences in terms of perioperative complications across study cohorts [21]. To date, previous surgery was reported in few than the 20% of patients and no data regarding the kind of surgery were provided, possibly lowering the statistical burden of extended adhesiolysis in the perioperative outcome assessment. Although a recent meta-analysis by Carbonara et. al[4] found a higher overall complications rate considering both matched and unmatched series in the TP vs RP approach, no differences were found in terms of CD ≥ 3a complications. Beyond first appearance, our findings are possibly in line with these reports non-focused on complex abdomens. Indeed, our highly surgically complex study population might have enhanced the pre-existing differences between approaches, thus bringing to the surface different safety profiles when it deals with previous major surgery. In this light, in our series open conversion rate was significantly higher in the transperitoneal group occurring in up to the 9% of cases while no conversions were recorded in the RP SP group, confirming its higher feasibility in these patients.

Secondly, as compared to the transperitoneal group RP SP-RAPN significantly reduced EBL, operative time and LOS also improving pain management and opioid administration. The convergence of these factors makes a strong argument in favor of both SP and RP adoption in minimizing the surgical impact on complex patients. From a perioperative standpoint, the advantages of the retroperitoneal approach have been widely discussed across current literature with several series identifying the surgeon preference as the main limiting factor in its adoption [4, 21, 24]. In this scenario, the introduction of SP surgical system may play a pivotal role making easier and more feasible dealing with the retroperitoneal space also in challenging cases [6, 25]. On top of that, given the median BMI up to 30 kg/m2 of our study population, the presence of abundant perinephric fat did not affect the feasibility of the SP RP approach, with reported perioperative outcomes consistent with current literature [19, 26].

Third, assessing the Trifecta achievement accordingly with Kaouk et al.[13] as a surrogate of surgical and oncological safety, the RP SP group showed significative higher values as compared to the MP procedures (Fig. 2). Acknowledging the burden of perioperative complications in this statistical significance, is interesting to notice that PSM rate was comparable among groups even in case of anterior lesions. With the advent of minimally invasive surgery, the retroperitoneal approach was always preferred by surgeons for managing posterior renal masses, while anterior lesions were typically managed transperitoneally[27]. Conversely, in our study a relatively high value of anterior lesion was found in the RP group. This factor is possibly driven by the high rate of SP-RAPN performed with supine LAA (76%), thus confirming its versatility and surgical benefits across a wide variety of procedures on the upper urinary tract and regardless to the tumor location [28].

This study is not devoid from limitations. Firstly, the retrospective nature of the analysis in conjunction with the single-center and multiple-surgeon setting may have introduced non-negligible biases. Secondly, the reproducibility of the reported results may have been reduced by the small sample size. To date, to the best of our knowledge this constitutes the larger series focused on perioperative outcomes of SP PN in patients with complex abdomens through current literature. Finally, the density of peritoneal adhesions was not determined intraoperatively due to the retrospective study design. Nevertheless, only patients with high risk of adhesions formation due to previous major procedures were included, possibly reducing the aforementioned flaws [29], [30]. Concluding, further muti-center series with longer follow up and larger sample size are still warranted to assess our preliminary outcomes.

In a cohort of patients with highly hostile abdomens treated with RAPN, single port retroperitoneal approach confirmed valuable perioperative outcomes reducing the perioperative complication rate as compared to the multiport transperitoneal approach. Additionally, in this patient setting retroperitoneal single port access minimized the overall surgical impact in patients by improving EBL, operative time, LOS and pain management. Further multicenter series with longer follow up assessment are still warranted to evaluate our preliminary results.

Acknowledgments

None.

Funding

No funding was received in each step of this research.

Conflicts of interest/Competing interests

Financial interests: The authors declare they have no financial interests.

Non-financial interests: None.

Authors contributions: Conceptualization Luca Lambertini, Simone Crivellaro; Data curation Gabriele Bignante, Francesco Lasorsa, Matteo Pacini, Francesca Valastro; Formal analysis; Luca Lambertini, Fabrizio Di Maida, Andrea Mari, Investigation Donato Cannoletta, Greta Pettenuzzo; Methodology Ruben Sauer, Juan Ramon Torres Anguiano; Supervision Alessandro Zucchi; Validation Andrea Minervini; Writing - original draft Luca lambertini; and Writing - review & editing Luca Lambertini, Simone Crivellaro.

Data Availability Statement: The data sets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics Committee Approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research Committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The present research was performed after local ethical commitment approval (University of Illinois in Chicago, 26^th June 2016) IRB 20201428.

Consent to participate: Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for publication of the collected data.

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Retroperitoneal Single Port vs Transperitoneal Multiport Robot Assisted Partial Nephrectomy (RAPN) in Patients with Highly Hostile Abdomens, a tertiary referral center comparative analysis

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