IRCCS Azienda Ospedaliero-Universitaria di Bologna, University of Bologna
Introduction: To assess the impact of three-dimensional (3D) modeling of renal mass on surgical planning and intraoperative guidance of arterial clamping and urinary collecting system (UCS) suture during partial nephrectomy (PN), compared to conventional 2D imaging.
Methods: Overall, 195 patients with cT1-T2 renal cancer eligible for PN were prospectively enrolled. Each patient underwent chest and abdominal computer tomography (CT) before surgery performed at single tertiary center. Overall, 175 patients effectively underwent PN were included. Population was stratified in two groups: study group (n=91), in which a 3D renal model was obtained from CT images and reviewed by surgeons; control group (n=84) in which only 2D imaging of CT scan was reviewed by surgeons. Outcomes of interest were followings: preoperative plan of arterial clamping (off clamping, non-selective vs. selective clamping) and of UCS suture, intraoperative effective clamping approach and need of UCS suture. Chi-square, T-student and Mann-Whitney U-test were used to compare the two groups. Multivariate logistic analysis was performed to identify independent predictors of selective or super-selective clamping and need of UCS suture
Results: The preoperative plan of arterial clamping was clampless, non-selective and selective in 36.9%, 54.8% and 8.3% of patients in control group vs. 24.2%, 24.2% and 51.6% of cases in study group, respectively (p < 0.001). During surgery, clampless, non-selective and selective PN was performed in 36.9%, 53.6% and 9.5% in control group vs. 28.6%, 35.2% and 36.3% in study group, respectively (p <001). Indeed, the selective clamping was performed in 61.7% of cases as previously planned by 3D model in study group and in 28.6% of cases as previously planned by 2D imaging in control group (p < 0.001). Preoperative UCS suture was planned in 50 (28.7%) patients with no difference between the two groups. However, the intraoperative UCS repair was performed in 7 (8.3%) patients of control group and in 21 (23.3%) patients of study group (p=0.007). At multivariate analysis, PADUA score (Odd Ratio [OR] 1.99), RENAL score (OR: 1.76) and the use of 3D model (OR 4.57) were independent predictors of UCS suturing (all p=0.004), while only the use of 3D model was found to be an independent predictor for selective clamping (OR 5.26, p<0.001).
Conclusions: The 3D-guided approach for PN improves the surgical planning with more effective strategy, increase adoption of selective clamping and need of UCS suture, with higher rate of intraoperative management as previously planned