The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surger
Objective: To compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN.
Design, setting, and participants: This study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1–2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions.
Outcome measurements and statistical analysis: The study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN.
Results and limitations: Baseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p < 0.05). This association was not affected by comorbidities, tumor dimension, PADUA score, or preoperative renal function (all p > 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81.
Conclusions: While cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity—especially in terms of complications—was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery.
Patient summary: In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity—especially in terms of complications—for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.
Carlo Andrea Bravi, Giuseppe Rosiello, Elio Mazzone, Andrea Minervini, Andrea Mari, Fabrizio Di Maida, Karim Bensalah, Benoit Peyronnet, Zine-Eddine Khene, Riccardo Schiavina, Lorenzo Bianchi, Alexandre Mottrie, Geert De Naeyer, Alessandro Antonelli, Maria Furlan, Koon Ho Rha, Ahmad Almujalhem, Ithaar Derweesh, Aaronw Bradshaw, Jihak Kaouk, Guilherme Sawczyn, Riccardo Bertolo, Alberto Breda, Francesco Montorsi, Umberto Capitanio, Alessandro Larcher, on behalf of the Junior ERUS/Young Academic Urologist Working Group on Robot-assisted Surgery
Unit of Urology, Division of Experimental Oncology, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy; Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium; Unit of Oncologic Minimally Invasive Urology and Andrology, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, Florence, Italy; Department of Urology, University of Rennes, Rennes, France; Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, Verona, Italy; Department of Urology, Spedali Civili Hospital, University of Brescia, Brescia, Italy; Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea; Department of Urology, Moores UCSD Cancer Center, University of California San Diego School of Medicine, San Diego, CA, USA; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Urology, Fundació Puigvert, Autonomous University of Barcelona, Barcelona, Spain
Source: Bravi C et al. The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery. European Urology Open Science, 2023. volume 49 Pages 71-77.