Background: In patients treated with partial nephrectomy, prior evidence showed that peri-operative outcomes, such as complications and ischemia time, improved as a function of the surgical experience of the surgeon, but data on functional outcomes after surgery are still scarce. Methods: We retrospectively analyzed data of 4011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. The operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery. Results: A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 37 (31%) and 55 (46%) surgeons contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to the learning curves of both approaches. In the laparoscopic group, 8% and 55% of patients developed AKI and recovered at least 90% of their baseline eGFR, respectively. After adjusting for confounders, we did not find evidence of an association between surgical experience and AKI after laparoscopic partial nephrectomy (odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p = 0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95% CI: 0.9988, 1.0005; p = 0.5). Among patients who underwent robot-assisted partial nephrectomy, AKI occurred in 11% of patients, whereas 54% recovered at least 90% of their baseline eGFR. On multivariable analyses, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95% CI: 0.9992, 1.0037; p = 0.2), with similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95% CI: 0.9980, 1.0022; p = 0.9). Virtually the same findings were found on sensitivity analyses. Conclusions: In patients treated with laparoscopic or robot-assisted partial nephrectomy, our data suggest that the surgical experience of the operating surgeon might not be a key determinant of functional recovery after surgery. This raises questions about the use of serum markers to assess functional recovery in patients with two kidneys and opens the discussion on what are the key steps of the procedure that allowed surgeons to achieve optimal outcomes since their initial cases.
Journal of clinical medicine. 2024 Oct 09*** epublish ***
Carlo Andrea Bravi, Junior ERUS/Young Academic Urologist Working Group on Robot-Assisted Surgery , Paolo Dell'Oglio, Angela Pecoraro, Zine-Eddine Khene, Riccardo Campi, Pietro Diana, Chiara Re, Carlo Giulioni, Alp Tuna Beksac, Riccardo Bertolo, Tarek Ajami, Kennedy Okhawere, Margaret Meagher, Arman Alimohammadi, Marco Borghesi, Andrea Mari, Daniele Amparore, Marco Roscigno, Umberto Anceschi, Giuseppe Simone, Nazareno Suardi, Antonio Galfano, Riccardo Schiavina, Federico Dehò, Karim Bensalah, Abdullah Erdem Canda, Vincenzo Ferrara, Antonio Alcaraz, Xu Zhang, Carlo Terrone, Shahrokh Shariat, Francesco Porpiglia, Alessandro Antonelli, Jihad Kaouk, Ketan Badani, Andrea Minervini, Ithaar Derweesh, Alberto Breda, Alexandre Mottrie, Francesco Montorsi, Alessandro Larcher
Department of Urology, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, UK., Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy., Department of Urology, Hospital Pederzoli, Peschiera del Garda, 37019 Verona, Italy., Department of Urology, University of Rennes, 35700 Rennes, France., Unit of Urological Robotic Surgery and Renal Transplantation, Department of Experimental and Clinical Medicine, Careggi Hospital, University of Florence, 50134 Florence, Italy., Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, 08025 Barcelona, Spain., Unit of Urology, Division of Oncology, URI, IRCCS Ospedale San Raffaele, 20132 Milan, Italy., Unit of Urology, Jesi Hospital, Jesi, 60035 Ancona, Italy., Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH 44106, USA., Department of Urology, San Carlo Di Nancy Hospital, 00165 Rome, Italy., Department of Urology, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain., Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA., Department of Urology, University of California, La Jolla, San Diego, CA 92103, USA., Department of Urology, Medical University of Vienna, 1090 Vienna, Austria., Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, 16132 Genova, Italy., Unit of Oncologic Minimally-Invasive Urology and Andrology-Careggi Hospital, Department of Clinical and Experimental Medicine, University of Florence, 50134 Florence, Italy., Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, 10043 Turin, Italy., ASST Papa Giovanni XXIII, 24125 Bergamo, Italy., Department of Urology, IRCCS "Regina Elena" National Cancer Institute, 00128 Rome, Italy., Department of Urology, University of Brescia, 25123 Brescia, Italy., Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy., ASST-Sette Laghi, Circolo & Fondazione Macchi Hospital, University of Insubria, 21100 Varese, Italy., Department of Urology, Koç University Hospital, Istanbul 34010, Turkey., Department of Urology, Chinese PLA General Hospital, Beijing 100091, China., Department of Urology, Azienda Ospedaliera Universitaria Integrata, University of Verona, 37126 Verona, Italy., Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, 9300 Aalst, Belgium.