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ORIGINAL ARTICLE   Free accessfree

Minerva Urologica e Nefrologica 2020 February;72(1):82-90

DOI: 10.23736/S0393-2249.19.03570-7


lingua: Inglese

Surgical quality, cancer control and functional preservation: introducing a novel trifecta for robot-assisted partial nephrectomy

Aldo BRASSETTI 1 , Umberto ANCESCHI 1, Riccardo BERTOLO 2, Mariaconsiglia FERRIERO 1, Gabriele TUDERTI 1, Umberto CAPITANIO 3, Alessandro LARCHER 3, Juan GARISTO 2, Alessandro ANTONELLI 4, Alexander MOTTIRE 5, Andrea MINERVINI 6, Paolo DELL’OGLIO 5, Alessandro VECCIA 4, Daniele AMPARORE 7, Rocco S. FLAMMIA 8, Andrea MARI 6, Francesco PORPIGLIA 7, Francesco MONTORSI 3, Jihad KAOUK 2, Riccardo AUTORINO 9, Marco CARINI 6, Michele GALLUCCI 8, Giuseppe SIMONE 1

1 Department of Urology, Regina Elena National Cancer Institute, Rome, Italy; 2 Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA; 3 Unit of Urology, Division of Experimental Oncology, Urological Research Institute (URI), San Raffaele Hospital IRCCS, Milan, Italy; 4 Department of Urology, Spedali Civili di Brescia, Brescia, Italy; 5 Department of Urology, OLV Hospital, Aalst, Belgium; 6 Department of Urology, Careggi Hospital, University of Florence, Florence, Italy; 7 Division of Urology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy; 8 Department of Urology, Umberto I Polyclinic, Sapienza University, Rome, Italy; 9 Division of Urology, Department of Surgery, Virginia Commonwealth University Health System, Richmond, VA, USA

BACKGROUND: In order to improve standard reporting of outcomes after partial nephrectomy, different “trifecta” systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes.
METHODS: A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival.
RESULTS: Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation.
CONCLUSIONS: This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality.

KEY WORDS: Kidney neoplasms; Nephrectomy; Survival

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