Single-Port vs Multiport Robot-Assisted Partial Nephrectomy: A Meta-Analysis

Abstract

Background:

Several centers have reported their experience with single-port robot-assisted partial nephrectomy (SP-RAPN); however, it is uncertain if utilization of this platform represents an improvement in outcomes compared to multiport robot-assisted partial nephrectomy (MP-RAPN). To evaluate this, we performed a meta-analysis to compare the perioperative, oncological, and functional outcomes between SP-RAPN and MP-RAPN.

Methods:

For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until January 1, 2023. A meta-analysis has been reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 and assessing the methodological quality of systematic reviews (AMSTAR) guidelines. The odds ratio (OR) and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI).

Results:

Of the 374 retrieved abstracts, 29 underwent full-text review, and 8 studies were included in the final analysis, comprising a total cohort of 1007 cases of RAPN (453 SP-RAPN cases and 554 MP-RAPN cases). Compared to MP-RAPN, the SP-RAPN group had a significantly longer ischemia time (MD = 4.6 minutes, 95% CI 2.8 to 6.3, p < 0.001), less estimated blood loss (MD = −12.4 mL, 95% CI −24.6 to −0.3, p = 0.045), higher blood transfusion rate (OR = 2.97, 95% CI 1.33 to 6.65, p = 0.008), and higher postoperative estimated glomerular filtration rate (eGFR) at 6 months (MD = 4.9 mL/min, 95% CI 0.2 to 9.7, p = 0.04). There was no significant difference in other outcomes between the two approaches, including the intraoperative complication, overall postoperative complication, minor postoperative complication (Clavien-Dindo I − II), major postoperative complication (Clavien-Dindo III–V), conversion to radical nephrectomy, pain score on day #1, pain score on discharge, morphine milligram equivalent usage, hospital stay, positive surgical margins, and postoperative eGFR.

Conclusions:

SP-RAPN represents an emerging technique using a novel platform. Initial studies have demonstrated that SP-RAPN is a safe and feasible approach to performing partial nephrectomy, although with inferior outcomes for ischemia time and blood transfusion rates. Further studies will be necessary to define the best usage of SP-RAPN within the surgeon's armamentarium.

Introduction

Minimally invasive techniques have become predominant in urological procedure.^1
–3 In the past 30 years, laparoscopic and especially robot-assisted procedures have been developed and widely adopted because of their advantages, including decreased postoperative pain, early recovery, a shorter hospital stay, and even lower cost.^4
–6 In urology, minimally invasive surgery (MIS) has been applied in numerous reconstructive and oncological procedures.^7
–9 Being a part of the concept of MIS, single-site robotic surgery has also been developed to improve efficiency and esthetic aspects, and without compromising the oncological outcomes.

Over the past decades, increased utilization of diagnostic imaging has resulted in the identification of more small renal masses.¹⁰ During this time, partial nephrectomy (PN) has become the preferred approach in the management of these localized renal tumors for demonstrating equivalent oncologic outcomes compared to radical nephrectomy, while preserving renal parenchyma and function. With advancements in robotic technology, as well as increase in collective surgeons' experiences, the outcomes of robot-assisted laparoscopic PN have been improved and several studies have shown decreasing complications, decreased positive surgical margins, and increasing overall preservation of renal function compared to conventional laparoscopic procedure.^11,12

In 2018, the Food and Drug Administration approved the next generation da Vinci (Intuitive Surgical, Inc., Sunnyvale, CA) single-port (SP) platform for use in urological procedure.¹³ This system utilizes articulating instruments and a flexible camera, which are placed through a single 25 mm port.¹⁴ After approval, several investigators reported on their experience in performing single-port robot-assisted partial nephrectomy (SP-RAPN) with the conclusion that this was a safe and feasible technique with this new platform.^15

–18 Nevertheless, the advantages and disadvantages of the SP-RAPN compared to multiport robot-assisted partial nephrectomy (MP-RAPN) are not clear, given that the available literature for SP-RAPN comprises single-institution or single-surgeon studies, which may not be broadly applicable to clinical practice. In this context, we performed a systematic review and meta-analysis to compare the perioperative, oncological, and functional outcomes between SP-RAPN and MP-RAPN.

Methods

Literature search

This study was conducted following the accepted methodology recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and assessing the methodological quality of systematic reviews (AMSTAR) guidelines for systematic reviews and meta-analyses (Supplementary Tables S1 and S2).^19,20 Three electronic databases, the Scopus, Web of Science (ISI), and PubMed, were searched to identify relevant studies regarding perioperative outcomes between SP-RAPN and MP-RAPN from their inception until January 1, 2023. The following search terms were used: (“partial nephrectomy” OR “heminephrectomy” OR “nephron sparing”) AND (“robot” OR “robotic” OR “robot-assisted”) AND (“single port” OR “single-port” OR “single site” OR “SP”). In addition, we performed a manual search of references from articles included in Scopus, PubMed, and Web of Science to avoid missing any relevant publication, as well as from reference lists of included articles.²¹

Selection criteria and abstract screening

The inclusion criteria were the relevant original articles reporting the perioperative, oncological, and functional outcomes between SP-RAPN and MP-RAPN. There was no restriction on study design, country, or language. Articles were excluded if they met one of the following exclusion criteria: (1) Not relevant to the study topic, in vitro or animal study; (2) cases report or series with less than five cases; (3) review, book chapter, or thesis; (4) conference papers, editorials, letters, oral presentation, correspondence, communications, and posters; and (5) duplicated articles. Two independent groups of reviewers (N.X.D. and D.N.M.P., and T.-D.H., T.M.T.T., and A.S.N.) performed title and abstract screening to select relevant articles. Eligible publications were further screened for inclusion in the systematic review and meta-analysis. Any disagreement was resolved by discussion and consensus if necessary.

Full-text screening and data extraction

Two groups of reviewers (N.X.D. and D.N.M.P., and T.-D.H., T.M.T.T., and A.S.N.) independently extracted data from the included studies using an Excel sheet. Two independent reviewers (H.G.V. and T.T.N.) validated the data to ensure the accuracy of all extracted data. Articles published by the same research group were checked for potential overlapping data based on the period of case recruitment, the center where the cases were recruited, and confirmation from the study authors when necessary. For those studies that selected the patients from the same institutions or databases, we chose the studies with the highest number of patients for the primary analyses.

Quality assessment

The Newcastle–Ottawa Scale (NOS) was used to evaluate the quality of studies included in our meta-analyses, in which stars were awarded for cohort or case–control studies (maximum nine stars) based on a developed checklist.²² Studies that were awarded at least six stars were considered moderate- to high-quality studies, whereas those with an NOS value of less than six were regarded as low-quality studies.²²

Statistical analysis

Comprehensive meta-analysis (Englewood, NJ) was used for statistical analyses. Among-study heterogeneity was assessed by the I ² statistic, which shows the total variation across studies that is not a result of chance.²³ An I ² statistic ranging from 25% to 49%, 50% to 74%, and ≥75% indicate low, moderate, and high amount of heterogeneity, respectively.²⁴ Sensitivity or subgroup analyses were performed to handle heterogeneity. We used risk ratios with 95% confidence intervals (CI) for categorical variables. The pooled results are presented as a forest plot using random-effects models. Egger's regression test and funnel plot were calculated to assess the presence of publication bias. A p-value of <0.05 was considered statistically significant.

Results

Search results and study characteristics

A total of 374 articles were identified from 3 electronic databases, including Scopus, PubMed, and Web of Science. After screening those articles by title and abstract, 29 articles were selected for full-text assessment. Upon full-text review, 21 articles were excluded owing to the absence of proper information, study design, and duplication. In total, 8 articles that met the inclusion criteria were included in the final cohort analysis, comprising 1007 cases of RAPN, including 453 SP-RAPN cases and 554 MP-RAPN cases.^{16,25

–30} The evidence acquisition flow chart is shown in Figure 1. The individual characteristics of all included studies are described in Table 1.

FIG. 1.

Evidence acquisition flow chart. Color images are available online.

Table 1.

Perioperative Outcomes of Robot-Assisted Partial Nephrectomy Performed Using the Single-Port vs Multiport Robotic System

Study ID (author/year/country)	Period	Study design	No of cases		Surgical approaches		Mean age, years		BMI		Left tumor, %		Tumor size, cm		Nephrometry score (RENAL score)		Operative time, minutes		Ischemia time, minutes		EBL, mL		PSM, %
Study ID (author/year/country)	Period	Study design	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP	SP	MP
Arkoncel/2011/Korea²⁵	2006–2010	Retrospective	35	35	Transperitoneal	Transperitoneal	52.7	51.7	24.3	24.9	NA	NA	NA	NA	NA	NA	187.5	171.7	29.5	28.8	257	242.5	2.8	5.7
Glaser/2022/USA¹⁶	2019–2020	Retrospective	26	52	Transperitoneal and retroperitoneal	Transperitoneal and retroperitoneal	58.4	53.2	32.5	33.8	53.8	42.3	3.5	3.3	NA	NA	183.9	208.6	NA	NA	NA	NA	NA	NA
Harrison/2022/USA²⁶	2019–2020	Retrospective	48	48	Transperitoneal and retroperitoneal	Transperitoneal and retroperitoneal	60.4	60.8	28.1	29.3	45.8	52.0	2.6	2.3	7.7	7	102.9	93	18.4	15.6	60.6	70.6	6.2	8.3
Komninos/2014/Korea²⁷	2006–2012	Retrospective	78	89	Transperitoneal	Transperitoneal	52.3	50.7	23.9	24.3	41.0	49.4	3	3.1	7.4	7.1	208	173	26.5	20.2	335	313	NA	NA
Na/2021/Korea²⁸	2018–2020	Retrospective	21	62	NA	NA	50	52.8	24.6	24.9	52.3	53.2	NA	NA	7.5	7.4	164.2	125.8	30	21.1	46.7	51.8	NA	NA
Shin/2014/Korea³²	2006–2012	Retrospective	79	80	Transperitoneal	Transperitoneal	52.4	52	24	24.6	43.0	50	3.4	3.1	7.5	7.1	210.3	183.1	26.5	19.8	NA	NA	2.5	8.7
Palacios/2022/USA²⁹	2013–2021	Retrospective	20	42	Retroperitoneal	Retroperitoneal	56.6	59.2	31.6	29.3	50	50	3.2	2.9	4.7	6	167.7	165.2	22.8	20.3	39.2	58.8	0	9.5
Okhawere/2022/USA³⁰	2015–2021	Prospective	146	146	NA	NA	58	59	30.2	30.1	42	44	2.9	3	6.4	6.4	137	142	18.3	13.8	89	112	6.2	4.8

BMI = body mass index; EBL = estimated blood loss; MP = multiport; NA = not available; PSM = positive surgical margin; SP = single port.

Perioperative outcomes among the patients who underwent RAPN

A summary of this meta-analysis for the perioperative outcomes of two groups (SP-RAPN and MP-RAPN) is demonstrated in Table 2. Compared to MP-RAPN, the SP-RAPN group had a significantly longer ischemia time (mean difference [MD] = 4.6 minutes, 95% CI 2.8 to 6.3, p < 0.001), less estimated blood loss (MD = −12.4 mL, 95% CI −24.6 to −0.3, p = 0.045), higher blood transfusion rate (odds ratio = 2.97, 95% CI 1.33 to 6.65, p = 0.008), and higher postoperative estimated glomerular filtration rate (eGFR) at 6 months (MD = 4.9 mL/min, 95% CI 0.2 to 9.7, p = 0.04).

Table 2.

Meta-Analysis of the Perioperative, Oncological, and Functional Outcomes Between Single-Port and Multiport Robot-Assisted Partial Nephrectomy

Outcomes	No. of studies	No. of patients		Heterogeneity		Overall effect
Outcomes	No. of studies	SP	MP	I ² (%)	p	MD/OR (95% CI)	p
Operative time, minutes	8	453	554	76	<0.001	13.1 (−0.5 to 26.7)	0.061
Ischemia time, minutes	7	425	495	46	0.084	4.6 (2.8 to 6.3)	<0.001
Intra-operative complication	4	188	215	0	0.479	1.59 (0.74 to 3.42)	0.234
Estimated blood loss, mL	6	348	422	0	0.894	−12.4 (−24.6 to −0.3)	0.045
Blood transfusion	4	218	256	0	0.853	2.97 (1.33 to 6.65)	0.008
Overall postoperative complication	6	432	492	0	0.544	1.36 (0.83 to 2.22)	0.209
Minor postoperative complication (Clavien-Dindo I–II)	4	173	222	21	0.283	0.75 (0.26 to 2.17)	0.607
Major postoperative complication (Clavien-Dindo III–V)	5	208	257	0	0.904	2.41 (0.73 to 7.86)	0.145
Conversion to radical nephrectomy	3	183	221	0	0.888	0.55 (0.16 to 1.85)	0.335
Positive surgical margin	5	328	351	0	0.476	0.71 (0.35 to 1.44)	0.355
Pain score at day #1	2	83	83	71	0.061	−0.04 (−1.21 to 1.13)	0.947
Pain score on discharge	3	162	163	41	0.171	−0.12 (−0.55 to 0.31)	0.589
MME	3	109	135	75	0.017	−3.9 (−19.0 to 11.1)	0.607
Hospital stay, days	3	338	350	0	0.783	−0.2 (−0.4 to 0.1)	0.235
Postoperative eGFR, mL/min	3	178	231	2.9	0.357	1.0 (−3.0 to 5.0)	0.623
Postoperative eGFR, mL/min at 6 months	2	100	142	0	0.822	4.9 (0.2 to 9.7)	0.04

Bold values indicate p < 0.05, denoting statistical significance.

CI = confidence interval; eGFR = estimated glomerular filtration rate; MD = mean difference; MME = morphine milligram equivalent; OR = odds ratio.

There was no significant difference in other outcomes between the two approaches, including the operation time, intraoperative complication, estimated blood loss, overall postoperative complication, minor postoperative complication (Clavien-Dindo I–II), major postoperative complication (Clavien-Dindo III–V), conversion to radical nephrectomy, pain score on day #1, pain score on discharge, morphine milligram equivalent (MME) usage, and hospital stay (Table 2 and Fig. 2 and Supplementary Figs. S1 and S2).

FIG. 2.

Forest plots for the meta-analysis comparing the outcomes between single-port and multiport robot-assisted partial nephrectomy: (A) Operative time; (B) ischemia time; (C) intraoperative complication; (D) estimated blood loss; and (E) blood transfusion. Color images are available online.

The heterogeneity of the operative time and MME usage was high (I ² = 76% and I ² = 75%, respectively). We used sensitivity analysis for the assessment of heterogeneity (Supplementary Fig. S4).

Oncological and functional outcomes among the patients who underwent RAPN

A summary of this meta-analysis for the oncological and functional outcomes of two groups (SP-RAPN and MP-RAPN) is displayed in Table 2. Compared to MP-RAPN, the SP-RAPN group had a significantly higher postoperative eGFR at 6 months (MD = 4.9 mL/min, 95% CI 0.2 to 9.7, p = 0.04). There was no significant difference in other oncological and functional outcomes between the two approaches, including positive surgical margins and postoperative eGFR (Table 2 and Supplementary Fig. S2).

Risk of bias assessment

The NOS tool was used to evaluate the study quality. Most of the included studies were retrospective studies (88% included studies). The number of stars awarded to each included study ranged from six to nine stars. Details of given stars within each NOS domain are shown in Supplementary Table S1.

Publication bias

We used Egger's regression test to assess the publication bias, and it did not suggest any evidence of bias confirmed by the Egger's regression test (p = 0.935). Moreover, the funnel plot showed no evidence of asymmetry (Supplementary Fig. S3).

Discussion

In the past three decades, urologists have tried to push the boundaries of MIS. During this time, several laparoscopic instruments and techniques have been developed to improve surgical outcomes.^3,31 In the evolution of MIS, decreasing the number of incisions and port to reduce morbidity as well as postoperative pain have culminated in single-site surgery. Kaouk and Goel first described single-site RAPN by using a multichannel gel port with a modified multiarm da Vinci S platform.¹⁵ However, urologists met some technical challenges such as motion restriction and instrument clashing, which limited broad adoption of these techniques. Furthermore, Komninos and colleagues showed inferior that the SP-RAPN group had longer mean operative time, warm ischemia time, and increased eGFR percentage change compared to MP-RAPN.²⁷

The development of da Vinci SP system has aimed to address the technical concerns of prior studies and overcome the difficulties associated with the utilization of multiarm surgical robots in performing SP procedure. This has led to a resurgence in interest in SP robotics, and as a result, several recent studies of SP-RAPN have been reported.^16,26

Perioperative outcomes are one of the most critical concerns in PN. Our analysis demonstrated that there was no significant difference in most perioperative outcomes studied, including operation time, overall complication, minor and major postoperative complication, and conversion rate, between the SP-RAPN and the MP-RAPN group. However, the SP-RAPN group had a significantly longer ischemia time, as well as higher blood transfusion rate. This may be attributable to inherent technical challenges with SP procedure, with greater motion restriction and instrument clashing with the SP approach or may be reflective of the surgeon learning curve with the relatively novel SP system.

One of the perceived advantages of the SP approach is decreased postoperative pain with decreased pain medication requirements, briefer hospital stays, and shorter convalescence. Although some studies reported the SP-RAPN group had lower opioid used in postoperative period or pain scale scores on the discharge day, in general, we found that there was no significant difference in postoperative pain scores, MME usage, or the hospital length stay between two approaches.^26,32

Our analysis showed that the SP-RAPN group had a significantly higher postoperative eGFR at 6 months postoperation compared to the MP-RAPN group, despite the nonsignificant differences in postoperative eGFR. Postoperative GFR depends on several factors such as warm ischemia, the percentage of parenchymal volume saved, baseline eGFR, baseline comorbidities, clamping technique, insufflation pressure, and the nephrorrhaphy technique.^33,34 The absence of data on these variables hindered our efforts to study if there is an impact of different robotic platform on eGFR.

Ultimately, oncological outcomes are the most important goal of cancer operation such as PN. There was no difference in the size and the nephrometry score of tumors between the SP-RAPN and MP-RAPN. Our meta-analysis found that there was no significant difference in positive surgical margin rates between the SP-RAPN and MP-RAPN. However, none of the studies reported cancer-specific survival.

Interestingly, the SP-RAPN groups had a higher blood transfusion rate, despite a lower estimated blood loss than MP-RAPN. This observation needs to be interpreted cautiously, as it might be related to inaccurate estimation of intraoperative blood loss, as most surgeons rely on visual methods rather than colorimetric and gravimetric methods.³⁵ Also, most of the studies did not specify the indication of transfusion, institutional protocol for transfusion, number of transfused units, or time of blood transfusion from operation. Therefore, future studies should focus on reporting the method of estimating blood loss, the indication of transfusion, and the time of blood transfusion.

The concept of achieving trifecta outcomes, including negative cancer margin, maximal renal function preserved, and no urological complication as a surrogate for procedural success, was introduced.³⁶ During this time, achieving the trifecta has become a benchmark for success during PN. However, the included studies have not compared it directly between the two groups and this may represent a subject of further investigation.

Our analysis showed that the SP-RAPN seemly had no significant difference in trifecta outcomes compared to the MP-RAPN group.

On the other hand, cosmesis may be an additional outcome of importance. In MIS, laparoendoscopic single-site procedure has served as the inspiration for the development of novel techniques and laparoscopic instruments, which will be a crucial step toward “scarless” laparoscopic procedure.^37
–39 Compared to the standard MP-RAPN, SP-RAPN may have a more favorable cosmetic outcome; however this was not evaluated objectively in any of the included studies, and should be evaluated in future studies.

Our study must be interpreted in light of certain limitations inherent to the meta-analysis study design. It is known that the SP surgical system was used first by very experienced surgeons already competent in MP-RAPN. Hence, the results from this meta-analysis may not be extrapolated to novice practitioners of SP-RAPN. Another limitation was the short-term follow-up period of currently published studies; thus, our meta-analysis could not compare long-term outcomes of overall survival, recurrence-free survival, and long-term kidney function. This may not be a major issue as early outcome data, as in our study, should be first verified before longer term data of novel technologies may be compared.

Despite these limitations, this study represents the most comprehensive meta-analysis of this subject with the largest robotic PN cohort. We believe this review is timely as it provides health systems and surgeons an insight to the potential advantages of the SP system before consideration of adopting it.

Conclusions

SP-RAPN represents an emerging technique with a novel technology. Initial studies have demonstrated that SP-RAPN is a safe and feasible approach to performing PN, although with inferior outcomes for ischemia time and blood transfusion rates. Further studies will be necessary to define the best usage of SP-RAPN within the surgeon's armamentarium.

Ethical Approval and Consent to Participate

Not applicable since this is a systematic review and meta-analysis.

Registration of Research

Registry used: Prospero.

Unique Identifying number or registration ID: CRD42022334577.

Availability of Supporting Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Figure S1

Supplementary Figure S2

Supplementary Figure S3

Supplementary Figure S4

Supplementary Table S1

Supplementary Table S2

Abbreviations Used

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