Predicting positive surgical margins in patients treated with robot-assisted partial nephrectomy: results from a prospectively maintained dataset of a single tertiary referral center

Abstract

Aim: To identify the incidence and evaluate predictors of positive surgical margins (PSMs) after robot-assisted partial nephrectomy (RAPN) in patients with clinical T1 renal cell carcinoma (RCC).

Methods: After securing ethics committee approval, we analyzed our institution’s prospectively maintained RCC database. Our cohort included 1611 patients who underwent RAPN between January 2017 and December 2022. Surgical specimens were evaluated using standard practices, and the International Society of Urological Pathology (ISUP) grading system was employed.

Results: The majority (69.5%) of the 1,611 patients were males. Median age and Body Mass Index were 62.6 years and 26.9 kg/m², respectively. Overall, 18.6% and 21.1% of the patients had an Eastern Cooperative Oncology Group (ECOG) score ≥ 1 and American Society of Anesthesiologists physical status (ASA PS) score ≥ 3, respectively. Surgical indications were elective in 90.5% of cases. The preoperative aspects and dimensions used for an anatomical (PADUA) score median was 8.0 (interquartile range: 7.0-9.5). The predominant histotype was clear cell RCC, accounting for 70.4% of the cohort. PSMs were detected in 6.7% of the patients. Multivariable logistic regression showed surgical indications with an odds ratio (OR) of 6.06 (P < 0.001), surface, intermediate, base (SIB) score > 1 with an OR of 2.37 (P = 0.001), and PADUA score with an OR of 1.10 (P = 0.006) were significant predictors of PSMs.

Conclusion: Attaining negative margins remains the oncological cornerstone of partial nephrectomy. Our data underscore that tumor-specific (PADUA score) and surgical parameters (imperative indication, SIB score > 1, off-clamp approach) are the principal determinants for PSMs after RAPN.

Keywords

Partial nephrectomy / positive margin / predictors / renal cancer / robotics

References

[1] EAU. Renal cell carcinoma. Available from: https://uroweb.org/guidelines/renal-cell-carcinoma. [Last accessed on 30 May 2024]

[2] Mari A,Tellini R.Oncologic outcomes in patients treated with endoscopic robot assisted simple enucleation (ERASE) for renal cell carcinoma: results from a tertiary referral center.Eur J Surg Oncol2019;45:1977-82

[3] Pecoraro A,Amparore D.New-onset chronic kidney disease after surgery for localised renal masses in patients with two kidneys and preserved renal function: a contemporary multicentre study.Eur Urol Open Sci2023;52:100-8 PMCID:PMC10240519

[4] Di Maida F,Lane BR.Predictors of positive surgical margins after robot-assisted partial nephrectomy for localized renal tumors: insights from a large multicenter international prospective observational project (the surface-intermediate-base margin score consortium).J Clin Med2022;11:1765 PMCID:PMC8999836

[5] Grosso AA,Di Maida F.Robotic partial nephrectomy with en bloc removal of a renal vein thrombus for multiple cT3a renal cell carcinoma lesions.Eur Urol Open Sci2022;44:33-6 PMCID:PMC9421307

[6] Mari A,Porpiglia F.Perioperative and mid-term oncological and functional outcomes after partial nephrectomy for complex (PADUA score ≥10) renal tumors: a prospective multicenter observational study (the RECORD2 Project).Eur Urol Focus2021;7:1371-9

[7] Tellini R,Tardanico R.Positive surgical margins predict progression-free survival after nephron-sparing surgery for renal cell carcinoma: results from a single center cohort of 459 cases with a minimum follow-up of 5 years.Clin Genitourin Cancer2019;17:e26-31

[8] Carbonara U,Capitanio U.Robot-assisted partial nephrectomy: 7-year outcomes.Minerva Urol Nephrol2021;73:540-3

[9] Antonelli A, Minervini A, Mari A, et al; RECORd Project-LUNA Foundation. TriMatch comparison of the efficacy of FloSeal versus TachoSil versus no hemostatic agents for partial nephrectomy: results from a large multicenter dataset.Int J Urol2015;22:47-52

[10] Minervini A,Kutikov A.Histopathological validation of the surface-intermediate-base margin score for standardized reporting of resection technique during nephron sparing surgery.J Urol2015;194:916-22

[11] Minervini A,Uzzo RG,Smaldone MC.Standardized reporting of resection technique during nephron-sparing surgery: the surface-intermediate-base margin score.Eur Urol2014;66:803-5

[12] Paner GP,Hansel DE,Lin DW.Updates in the eighth edition of the tumor-node-metastasis staging classification for urologic cancers.Eur Urol2018;73:560-9

[13] Minervini A,Sessa F.Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence.Minerva Urol Nefrol2017;69:523-38

[14] Di Maida F, Campi R, Grosso AA, et al; Collaborators. Prognostic features of upstaged pT3a renal tumors with fat invasion after robot-assisted partial nephrectomy: is it time for a new subclassification?.Eur J Surg Oncol2023;49:862-7

[15] Campi R, Grosso AA, Lane BR, et al; SIB International Consortium. Impact of Trifecta definition on rates and predictors of “successful” robotic partial nephrectomy for localized renal masses: results from the Surface-Intermediate-Base Margin Score International Consortium.Minerva Urol Nephrol2022;74:186-93

[16] Minervini A,Lane BR.Impact of resection technique on perioperative outcomes and surgical margins after partial nephrectomy for localized renal masses: a prospective multicenter study.J Urol2020;203:496-504

[17] Porpiglia F.Re: Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: systematic review of the literature and meta-analysis of prevalence.Eur Urol2018;73:480-1

[18] Di Maida F,Sforza S.Surgical management of synchronous, bilateral renal masses: a 1-decade referral center experience.Eur Urol Focus2022;8:1309-17

[19] Grosso AA,Tellini R.Robot-assisted partial nephrectomy with 3D preoperative surgical planning: video presentation of the florentine experience.Int Braz J Urol2021;47:1272-3 PMCID:PMC8486435

[20] Campi R, Di Maida F, Lane BR, et al; Members of the SIB International Consortium. Impact of surgical approach and resection technique on the risk of Trifecta Failure after partial nephrectomy for highly complex renal masses.Eur J Surg Oncol2022;48:687-93

[21] Tuderti G,Anceschi U.Assessing the trade-off between the safety and effectiveness of off-clamp robotic partial nephrectomy for renal masses with a high RENAL score: a propensity score-matched comparison of perioperative and functional outcomes in a multicenter analysis.Eur Urol Focus2023;9:1037-43

[22] Bove P,Sandri M.Deviation from the protocol of a randomized clinical trial comparing on-clamp versus off-clamp laparoscopic partial nephrectomy (CLOCK II laparoscopic study): a real-life analysis.J Urol2021;205:678-85

[23] Antonelli A, Cindolo L, Sandri M, et al; AGILE Group (Italian Group for Advanced Laparo-Endoscopic Surgery). Is off-clamp robot-assisted partial nephrectomy beneficial for renal function? Data from the CLOCK trial.BJU Int2022;129:217-24

[24] Capitanio U,Cianflone F.Hypertension and cardiovascular morbidity following surgery for kidney cancer.Eur Urol Oncol2020;3:209-15

[25] Anceschi U,Tuderti G.Risk factors for progression of chronic kidney disease after robotic partial nephrectomy in elderly patients: results from a multi-institutional collaborative series.Minerva Urol Nephrol2022;74:452-60

[26] Stencel MG,Yabes JG,Davies BJ.Partial nephrectomy drives the association between high-volume centers and decreased mortality: a surveillance, epidemiology, and end results-medicare analysis.Urology2023;181:55-62

[27] Minervini A,Masieri L.Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results.Surg Endosc2015;29:1241-9

[28] Minervini A,Di Maida F.Tumor-parenchyma interface and long-term oncologic outcomes after robotic tumor enucleation for sporadic renal cell carcinoma.Urol Oncol2018;36:527.e1-11

[29] Minervini A,Di Maida F.How far is too far? Exploring the indications for robotic partial nephrectomy in a highly complex kidney tumor.Int Braz J Urol2020;46:871-2 PMCID:PMC7822367

[30] Grosso AA,Di Maida F,Mari A.Three-dimensional reconstruction and intraoperative ultrasonography: crucial tools to safely approach highly complex renal masses.Int Braz J Urol2022;48:996-7 PMCID:PMC9747021