With increasing use of partial nephrectomy (PN) to treat complex T1 tumours, the risk of conversion to radical nephrectomy (RN) increases. In this study the authors look at the incidence of conversion of robotic PN (RPN) to RN and analysed the preoperative factors associated with it. Between 2010 and 2015, 1023 patients were identified who underwent RPN. Of these 32 (3.1%) required conversion to RN. These conversions were classified into two groups, anticipated and unanticipated conversions based on preoperative likelihood. It was found that 71.9% (23) conversions were anticipated while 28.1% (9) were unanticipated. The most common reasons for conversions were hilar involvement (8; 25%); positive margins on frozen section (7; 21.8%); suspected advanced disease (5; 15.6%); and failure to progress due to anatomical reasons and adherent fat (5; 15.6%). Other reasons included intraoperative haemorrhage (two cases), renal vein tumour thrombus found intraoperatively (one case), and postoperative large haematoma formation (one case) due to anticoagulant misuse. One patient had RN prompted by unexplained hypotension in absence of surgical bleeding, refractory to pharmacological management. Patients requiring conversions were older and had higher Charlson Comorbidity Index with higher prevalence of chronic kidney disease. Tumour size (5cm vs. 3.1cm) and higher R.E.N.A.L. Nephrometry Score (9 vs. 8; p=0.01) were also greater. Tumours requiring conversion were in particular more likely to be close to the collecting system or renal sinus. Exophytic / endophytic properties were not associated factors (p=0.32). On final histopathological analysis, no significant difference was found in the incidence of malignant tumours or tumour grade. However, converted cases were more likely to have higher pT3 disease (36.7 vs. 10.1%). Median estimated glomerular filtration rate (eGFR) preservation was lower in the conversion group but oncological outcomes were the same. – ZA
When partial nephrectomy is unsuccessful
Reviewed by Zeeshan Aslam
When partial nephrectomy is unsuccessful: understanding the reasons for conversion from robotic partial to radical nephrectomy at a tertiary referral center.
CONTRIBUTOR
Zeeshan Aslam
Ninewells Hospital, Dundee, UK; Surgical Tutor, RCPS Glasgow.
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