(UroToday.com) At the WCET 2024 conference in Seoul, Dr. Nicolas Soputro from the Department of Urology at the Glickman Urological & Kidney Institute, Cleveland Clinic, presented a significant study focused on developing a patient-specific algorithm to enhance clinical decision-making in robotic partial nephrectomy (RPN). This research addresses the comparative utility of Single Port (SP) versus Multi Port (MP) robotic approaches, with the goal of improving the selection process and optimizing surgical outcomes.
The study involved a comprehensive retrospective review of the Single Port Advanced Research Consortium (SPARC) database, a multi-institutional and meticulously maintained resource covering patient data from 2019 to 2023. The analysis encompassed a total of 1,021 patients who underwent either SP or MP-RPN, with the objective of identifying key factors that could better inform the choice between these two approaches, guiding surgeons toward more personalized treatment strategies.
Of the patients included in the study, 189 (18.5%) underwent SP-RPN, while the remaining 832 (81.5%) were treated using the MP-RPN technique. The analysis identified several statistically significant predictors favoring the use of SP-RPN. Specifically, patients with a lower comorbidity profile, a significant history of abdominal surgery (as indicated by a higher Hostile Abdomen Index1, or HAI), and lower complexity tumors were more likely to benefit from the SP approach.
These predictors were combined into a nomogram—a statistical tool designed to estimate the likelihood of a particular outcome based on individual patient characteristics. The nomogram demonstrated strong predictive performance, with an Area Under the Curve (AUC) of 0.79, indicating a high level of accuracy in determining the appropriate surgical approach. An optimal cutoff point was identified, where likelihood ratios above 0.12 suggested a preference for SP-RPN. Importantly, all SP-RPN cases that exceeded this cutoff exhibited improved perioperative outcomes, including shorter ischemia times and reduced intraoperative blood loss.
Dr. Soputro concluded his presentation by explaining that several factors were integrated into the nomogram, including the ASA score, Hostile Abdomen Index, largest tumor diameter, exophytic/endophytic nature of the tumor, and tumor location relative to polar lines. These factors were combined to calculate a total score, which was then used to determine the likelihood of SP-RPN. The closer the likelihood value was to 0.7, the more beneficial the SP approach was expected to be. He also acknowledged that the nomogram was developed retrospectively and included cases that were part of the learning curve, as well as heterogeneous practice patterns across multiple institutions. Dr. Soputro emphasized that this nomogram will continue to evolve and hopes it will be integrated into clinical practice in the future.
The session also featured an engaging Q&A segment. A moderator inquired whether all participating institutions had access to both Single Port and Multi Port robotic systems and whether accessibility could be a confounding factor in the nomogram’s development. Dr. Soputro confirmed that all institutions involved in the study had access to both types of robots. Another moderator congratulated Dr. Soputro on the creation of the nomogram and asked whether easier cases were more likely to be assigned to the Single Port approach. Dr. Soputro agreed that this was correct.
The discussion then turned to how the nomogram could be applied in clinical practice. Dr. Soputro noted that the nomogram reflects the early adoption of SP techniques, particularly in the context of the SP procedures. He mentioned the need for a more conservative approach in the initial phases, favoring smaller tumor sizes and patients with fewer comorbidities. He also highlighted that over the past few years, an increasing number of cases have been managed using the SP approach, with the most recent 200 out of 400 patients having an average renal score between 7 and 8.
In conclusion, this study offers a valuable contribution to the ongoing evolution of robotic partial nephrectomy. The patient-specific algorithm developed by Dr. Soputro and his team is poised to become an essential tool in clinical practice, guiding surgeons in making well-informed decisions tailored to the unique characteristics of each patient. As robotic surgery continues to advance, such innovations are critical in ensuring that patients receive the highest standard of care.
The authors of the study reported no conflicts of interest, and the research was conducted without external funding, underscoring the independence and rigor of their findings.
Presented by: Nicolas Soputro, MD, Department of Urology, Glickman Urological & Kidney Institute, Cleveland Clinic.
Written by: Seyedamirvala Saadat, Research Specialist at Department of Urology, University of California Irvine, @Val_Saadat on X during the 2024 World Congress of Endourology and Uro-Technology: August 12 -16, 2024, Seoul, South Korea
References:- Goldfarb MA, Protyniak B, Schultheis M. Hostile Abdomen Index Risk Stratification and Laparoscopic Complications. JSLS. 2014;18(1):14-19.