Effectiveness of soft coagulation in robot-assisted partial nephrectomy in preventing pseudoaneurysms and its influence on renal function based on propensity score-matched analysis
Highlight box
Key findings
• Soft coagulation use in robot-assisted partial nephrectomy (RAPN) reduces the incidence of renal artery pseudoaneurysm (RAP).
What is known and what is new?
• RAP is a severe and life-threatening complication of partial nephrectomy. The use of a monopolar soft coagulation system for homeostasis during surgical resection was reported to potentially prevent post-surgical RAP development.
• This study tested and validated this hypothesis in 208 patients who underwent RAPN for renal tumors.
• Soft coagulation use did not influence changes in estimated glomerular filtration rate over time.
What is the implication, and what should change now?
• The incidence of post-surgical complications can be reduced by using soft coagulation during RAPN in institutions where the technology is available.
Introduction
The diagnosis and treatment of renal cell carcinoma are rapidly changing. Among these changes, small renal masses are on the rise, likely due to the increased likelihood of incidental detection in computed tomography (CT) scans performed for other medical conditions (1,2).
Partial nephrectomy is the standard treatment for small renal cell carcinoma (3).
Partial nephrectomy has become superior to total nephrectomy in terms of the preservation of renal function and oncological outcomes, and the widespread use of robotic surgery has further accelerated this trend (4-7). Robot-assisted partial nephrectomy (RAPN) is performed at several centers in Japan (8).
Renal artery pseudoaneurysm (RAP) is one of the most stressful and life-threatening complications of partial nephrectomies. RAP following RAPN is typically reported in the range of 1–5%. Factors such as the retroperitoneal approach, tumors located deeply within the renal parenchyma, larger tumor size, more complex tumor anatomy, renal sinus exposure, and young age (under 56 years) can affect its development (7,9). A review study reported that RAP after partial nephrectomy occurred at a mean of 14.9 days; however, since it could appear within 1–90 days, care should be taken for up to approximately 3 months after surgery (10). Few previous studies mentioned the possibility that the use of a monopolar SOFT COAG (VIO300D, ERBE, Tubingen, Germany) system for hemostasis would prevent RAP development following surgical resections; however, comparison reports on this point remain scarce (7,11,12). We hypothesized that the use of a soft coagulation system would decrease the incidence of RAP after RAPN. We aimed to test this hypothesis and assess the changes in renal function over time in patients after RAPN with or without a soft coagulation system. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-24-84/rc).
Methods
Patients
This single-center retrospective comparative study included 208 patients who underwent RAPN for renal tumors at Jichi Medical University Hospital from May 2016 to March 2023. Ten patients who could not undergo contrast-enhanced CT because of asthma, contrast allergy, or renal dysfunction were excluded. Renal function, with an estimated glomerular filtration rate (eGFR) greater than 30, was considered acceptable for contrast medium. Patients were divided into two groups: those who used the soft coagulation system for hemostasis after tumor resection (soft coagulation users) and those who did not (non-users). Soft coagulation technology has been in use since January 2021 and has been used in almost all cases since then.
Ethics
The study was approved by the Institutional Review Board of Jichi Medical University Hospital (No. A22-023) and conformed to the provisions of the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from all participants for inclusion in the study.
Endpoints
The primary endpoint was the incidence of RAP after RAPN, and the secondary endpoint was the rate of postoperative eGFR change between soft coagulation users and non-users. RAP development was assessed by contrast-enhanced CT performed at 1, 3, and 6 months postoperatively or later, according to previous reports. The eGFR was assessed at preoperative baseline, 1, 3, and 12 months postoperatively. The percent change in eGFR was expressed as the ratio of the postoperative value to the preoperative baseline value. The eGFR was calculated using the Modification of Diet in Renal Disease equation: 186 × (creatinine/88.4)−1.154 × (age)−0.203 × (0.742 if female) (13).
Surgical techniques
All operations were performed using da Vinci Si and Xi robotic platforms (Intuitive Surgical Inc., Sunnyvale, CA, USA). Six or seven ports were placed, two or three of which were by assistive surgeons. The decision to use a transperitoneal or retroperitoneal approach was based on the location of the tumor on preliminary imaging. All renal arteries were secured and clamped, and the renal veins were checked by the surgeon but were not secured. An intraoperative ultrasonographic probe (L43K; Hitachi, Tokyo, Japan) was used to confirm the tumor margins. We used the TilePro system to confirm the tumor location using ultrasonography in real-time. After tumor resection, the assistant clipped any vessels that were evident at the tumor base. In addition, a soft coagulation system was used for hemostasis, with the output mode set to SOFT COAG (effect7/60W) and employing a ball-type IO-advanced electrode. In the soft coagulation user group, the assistant initiated hemostatic manipulation simultaneously with the surgeon’s tumor resection if there was an obvious bleeding point. Among patients who underwent nephrography, 3-0 V-Loc (15 cm 180 CV23; Covidien, New Haven, CT, USA) sutures were used for inner closure. Early unclamping was performed to confirm the extent of hemorrhage, and renorrhaphy was performed using a 2-0 V-Loc (20 cm 180 GS21; Covidien). During this period, an assistant performed the hemostatic surgery with soft coagulation (Video 1).
Statistical analysis
In univariate comparisons, categorical data were compared using the chi-square test, and continuous data were compared using the Mann-Whitney U test.
We performed one-to-one propensity score matching between soft coagulation therapy users and non-users to balance the patients’ preoperative background characteristics. The propensity scores of each group were calculated using logistic regression of preoperative variables, including age, sex, body mass index, American Society of Anesthesiologists Performance Status (ASA-PS), tumor laterality, size and location, approach to the tumor (transperitoneal or retroperitoneal), and RENAL nephrometry score. Regarding endpoint assessments, multivariate logistic regression and multivariate linear regression analyses were performed for the incidence of RAP after RAPN and the rate of postoperative eGFR change, respectively. Multivariate analyses were adjusted for age, sex, body mass index, ASA-PS, tumor laterality, size and location, approach to the tumor (transperitoneal or retroperitoneal), RENAL nephrometry score, and use of a soft coagulation system. All statistical analyses were performed using JMP version 17 (SAS Institute, Cary, NC, USA), and statistical significance was set at P<0.05.
Results
Eighty soft coagulation users and 118 non-users were included in the present study. The patient background characteristics are shown in Table 1. One case of RAP occurred in soft coagulation therapy users and 23 cases in non-users (1.3% vs. 19.5%).
Table 1
| Variables | Before propensity score matching | After propensity score matching | |||||
|---|---|---|---|---|---|---|---|
| Users (n=80) | Non-users (n=118) | P value | Users (n=80) | Non-users (n=80) | P value | ||
| Age (years)1 | 67 [57–73] | 63 [55–70] | 0.049 | 67 [57–73] | 65 [56–72] | 0.49 | |
| Female sex2 | 46 (57.5) | 47 (39.8) | 0.02 | 46 (57.5) | 40 (50.0) | 0.43 | |
| Body mass index (kg/m2)1 | 24.9 [23.0–27.0] | 24.2 [21.5–27.1] | 0.26 | 24.9 [23.0–27.0] | 24.2 [21.7–27.8] | 0.51 | |
| ASA-PS2 | 0.006 | 0.006 | |||||
| 1 | 2 (2.5) | 20 (16.9) | 2 (2.5) | 8 (10.0) | |||
| 2 | 69 (86.3) | 86 (72.9) | 69 (86.3) | 61 (76.3) | |||
| 3 | 9 (11.3) | 12 (10.2) | 9 (11.3) | 11 (13.8) | |||
| Anticoagulant agent users2 | 18 (22.5) | 19 (16.1) | 0.34 | 18 (22.5) | 14 (17.5) | 0.55 | |
| Right side2 | 39 (48.8) | 57 (48.3) | >0.99 | 39 (48.8) | 37 (46.3) | 0.87 | |
| Tumor size (mm)1 | 2.5 [1.9–3.3] | 2.33 [1.80–2.98] | 0.11 | 2.5 [1.9–3.3] | 2.4 [2.0–3.0] | 0.62 | |
| RENAL nephrometry score1 | 7 [5–8] | 7 [5–8] | 0.97 | 7 [5–8] | 7 [5–8] | 0.68 | |
| Hilar tumor2 | 14 (17.5) | 17 (14.4) | 0.70 | 14 (17.5) | 12 (15.0) | 0.83 | |
| Retroperitoneal approach2 | 23 (28.8) | 36 (30.5) | 0.92 | 23 (28.8) | 25 (31.3) | 0.86 | |
Data are presented as n (%) or median [IQR]. 1, continuous data were compared using the Mann-Whitney U test; 2, categorical data were compared using the chi-square test. ASA-PS, American Society of Anesthesiologists Physical Status; IQR, interquartile range.
After propensity score matching, 80 patients were assigned to each group (Table 1). The surgical and pathological outcomes and percentage change in eGFR after propensity score matching are shown in Table 2. No significant differences were observed between soft coagulation users and non-users in console time (136 vs. 130 min, P=0.41), warm ischemic time (19 vs. 16 min, P=0.08), and bleeding (100 vs. 50 mL, P=0.24), respectively. A slight significant difference was observed in the resection time (10 vs. 8 min, P<0.001). One and eighteen cases of RAPs were detected in soft coagulation users and non-users, respectively (1.3% vs. 22.5%, P<0.001). Two cases of positive surgical margin in the soft coagulation users and one case in the non-users were observed (2.5% vs. 1.3%, P=0.30). Regarding complications, one case of Grade 3 or higher complication according to the Clavien-Dindo classification was observed in the non-users group, where the patient underwent embolization due to postoperative bleeding. In terms of renal function, there was a decrease in eGFR in the early postoperative period, but it improved over time to approximately the same level as the preoperative value. There were no complications of Grade 3 or higher in the soft coagulation group.
Table 2
| Variables | Soft coagulation use | P value | |
|---|---|---|---|
| Users (n=80) | Non-users (n=80) | ||
| Operation time, min1 | 191 [166–216] | 188 [157–218] | 0.79 |
| Console time, min1 | 136 [118–159] | 130 [117–159] | 0.41 |
| Warm ischemic time, min1 | 19 [14–23] | 16 [13–21] | 0.08 |
| Resection time, min1 | 10 [8–14] | 8 [6–10] | <0.001 |
| Renorrhaphy time, min1 | 20 [17–26] | 22 [17–28] | 0.20 |
| Blood loss, mL1 | 100 [30–127] | 50 [30–100] | 0.24 |
| Resect weight, g1 | 11 [6–24] | 10 [6–16] | 0.22 |
| Pseudoaneurysm development2 | 1 (1.3) | 18 (22.5) | <0.001 |
| Urinoma development2 | 3 (3.8) | – | 0.24 |
| Other complications2* | – | 1 (1.3) | 0.84 |
| Pathology2 | 0.21 | ||
| Clear cell | 67 (83.8) | 58 (72.5) | |
| Non-clear cell | 8 (10.0) | 10 (12.5) | |
| Benign | 5 (6.3) | 12 (15.0) | |
| Pathological stage2 | 0.21 | ||
| Benign | 5 (6.3) | 12 (15.0) | |
| pT1a | 71 (88.8) | 63 (78.8) | |
| pT1b | 1 (1.3) | 3 (3.8) | |
| pT3a | 3 (3.8) | 2 (2.5) | |
| Positive surgical margin1 | 2 (2.5) | 1 (1.3) | 0.30 |
| Percentage change of estimated glomerular filtration rate, %1 | |||
| 1 month later | 89 [82–95] | 96 [87–103] | <0.001 |
| 3 months later | 87 [82–97] | 93 [87–102] | 0.009 |
| 12 months later | 88 [81–95] | 92 [85–97] | 0.15 |
Data are presented as n (%) or median [IQR]. *, Grade 3 or higher of Clavien-Dindo classification. 1, continuous data were compared using the Mann-Whitney U test; 2, categorical data were compared using the chi-square test. IQR, interquartile range.
After propensity score matching was performed, a multivariate analysis was performed for the development of RAP, and the results are shown in Table 3. The only significant difference was found in the use of soft coagulation [odds ratio, 0.05; 95% confidence interval (CI): 0.01 to 0.44; P=0.007]. In addition, there was no significant difference between the RENAL nephrometry score and the development of RAP (odds ratio, 1.54; 95% CI: 0.98 to 2.44; P=0.06).
Table 3
| Variables | OR (95% CI) | P value |
|---|---|---|
| Age, years (continuous) | 0.97 (0.91–1.04) | 0.49 |
| Female (vs. male) | 1.06 (0.27–4.04) | 0.93 |
| Body mass index (continuous) | 1.04 (0.87–1.24) | 0.65 |
| ASA-PS | 0.37 (0.084–1.631) | 0.19 |
| Anticoagulant agent use (vs. no) | 0.82 (0.13–5.05) | 0.84 |
| Right (vs. left) | 0.41 (0.10–1.72) | 0.23 |
| Tumor size, mm (continuous) | 0.71 (0.31–1.64) | 0.44 |
| RENAL nephrometry score, by one point | 1.54 (0.98–2.44) | 0.06 |
| Hilar tumor (vs. no) | 0.18 (0.01–2.21) | 0.19 |
| Retroperitoneal approach (vs. intraperitoneal) | 2.38 (0.59–9.54) | 0.22 |
| Soft-coagulation users (vs. non-users) | 0.05 (0.01–0.44) | 0.007 |
OR, odds ratio; CI, confidence interval; ASA-PS, American Society of Anesthesiologists Physical Status.
Multivariate analysis was also performed on the percentage change in eGFR at 1, 3, and 12 months postoperatively (Table 4). At 1 month postoperatively, there was a significant difference in the rate of change in eGFR between patients with and without soft coagulation use (estimate =−6.4%; 95% CI: −10.1 to −2.7; P=0.001); however, at 3 and 12 months postoperatively, no significant difference was observed between the two groups.
Table 4
| Variables | Percentage change in estimated glomerular filtration rate | |||||||
|---|---|---|---|---|---|---|---|---|
| 1 month later | 3 months later | 12 months later | ||||||
| β (95% CI), % | P value | β (95% CI), % | P value | β (95% CI), % | P value | |||
| Age, years (continuous) | 0.1 (0.0 to 0.3) | 0.12 | 0.2 (0.0 to 0.4) | 0.048 | 0.1 (−0.1 to 0.3) | 0.25 | ||
| Female (vs. male) | 3.8 (−0.1 to 7.7) | 0.06 | 4.2 (0.2 to 8.3) | 0.04 | 2.1 (−2.4 to 6.6) | 0.36 | ||
| Body mass index (continuous) | −0.1 (−0.6 to 0.4) | 0.71 | 0.1 (−0.5 to 0.6) | 0.84 | 0.0 (−0.5 to 0.6) | 0.87 | ||
| ASA-PS | −2.2 (−7.0 to 2.6) | 0.37 | −0.5 (−5.5 to 4.6) | 0.86 | −2.7 (−8.3 to 3.0) | 0.35 | ||
| Anticoagulant agent use (vs. no) | −4.1 (−9.3 to 1.0) | 0.12 | −3.2 (−8.4 to 2.0) | 0.23 | 0.5 (−5.2 to 6.3) | 0.85 | ||
| Right (vs. left) | 0.3 (−3.7 to 4.3) | 0.87 | −1.6 (−5.7 to 2.5) | 0.46 | 1.0 (−3.5 to 5.5) | 0.66 | ||
| Tumor size, mm (continuous) | −2.1 (−4.6 to 0.3) | 0.09 | −0.8 (−3.4 to 1.8) | 0.54 | −0.4 (−3.4 to 2.6) | 0.80 | ||
| RENAL nephrometry score, by one point | −0.3 (−1.6 to 1.0) | 0.66 | −0.6 (−1.9 to 0.7) | 0.38 | 0.0 (−1.5 to 1.4) | 0.96 | ||
| Hilar tumor (vs. no) | 5.4 (−0.1 to 10.9) | 0.06 | 2.8 (−2.7 to 8.3) | 0.32 | 1.6 (−4.6 to 7.7) | 0.62 | ||
| Retroperitoneal approach (vs. intraperitoneal) | 0.0 (−4.3 to 4.2) | 0.99 | 1.8 (−2.5 to 6.1) | 0.41 | −2.3 (−7.1 to 2.4) | 0.34 | ||
| Soft-coagulation users (vs. non-users) | −6.4 (−10.1 to −2.7) | 0.001 | −3.6 (−7.5 to −0.3) | 0.07 | −1.1 (−5.5 to 3.3) | 0.61 | ||
CI, confidence interval; ASA-PS, American Society of Anesthesiologists Physical Status.
Discussion
In the present study, we reported that soft coagulation in RAPN reduces the development of RAP and affects renal function during the early postoperative period. However, the effects of reduced renal function disappeared in the long term.
Two mechanisms have been proposed for the development of RAP after partial nephrectomy: (I) inadvertent vascular injury during tumor resection and (II) vascular injury during parenchymectomy (14). When patient activities increase a few days after surgery, blood flow to the surgical wound increases, and blood accumulates outside the blood vessels and then forms an aneurysm (15). The actual incidence of RAP requiring transarterial embolization after RAPN is estimated to be around 1% (16,17). Manipulations during tumor resection and renorrhaphy to stop bleeding and prevent urinary fistulas are linked to the development of RAP, and there is a risk of developing RAP during a certain period after surgery, making it a very distressing complication for surgeons and the patient.
Based on reports of an association between RAP development and renorrhaphy, hemostasis using a soft coagulation system is effective. The soft coagulation technology suppresses spark discharge by controlling the voltage and denatures proteins only by Joule heat without causing carbonization or evaporation of tissues to produce a hemostatic effect. The depth of thermal denaturation required for hemostasis in partial nephrectomy is thought to be about 4.6 mm, and the soft coagulation technology has been reported to provide stable hemostasis up to this depth (3). Previous studies have used blunt dissection and soft coagulation systems (6,11,12,18). Surgical approaches without parenchymal renorrhaphy are feasible and can reduce the incidence of RAP (12). Although there have been reports that the use of soft coagulation instead of parenchymal renorrhaphy can reduce the development of RAP, this is the first report to mention the use of soft coagulation in addition to conventional parenchymal renorrhaphy to reduce RAP. There could be a possible risk of suture breakage with the combined use of renorrhaphy and soft coagulation, although this has not occurred, and no complications such as postoperative hemorrhage have occurred. Soft coagulation effectively cauterizes the blood vessels in the hemorrhagic area, which could have contributed to the reduced incidence of RAP.
In this study, we showed a significant difference in the rate of change in eGFR at 1 month postoperatively, and one of the possible effects of this difference was the use of soft coagulation. Comparing the rate of eGFR decline at 1 month postoperatively in RAPN for soft coagulation users; it has been reported that the use of soft coagulation therapy was effective in reducing ischemic time and preserving renal function (18); however, our results differed. This difference could be because our institution used a combination of soft coagulation and renorrhaphy. However, this difference was no longer significant at 3 and 12 months postoperatively. In the early postoperative period, the renal parenchyma can still be affected by resection, coagulation, and suturing. Nevertheless, we also recognized the reports showing that soft coagulation is useful in maintaining renal function and reducing complications in partial nephrectomy (3). Even our results showed that the difference became smaller over time, and the effect on renal function was acceptable in the soft coagulation group.
Regarding changes in renal function after partial nephrectomy, some reports have suggested that the course changes in the presence or absence of chronic kidney disease (CKD). Regarding long-term functional outcomes after partial nephrectomy, the probability of worsening renal function is low in the presence of pre-existing CKD (19-21). The higher the preoperative CKD stage, the less likely the patient is to experience CKD upstaging. Therefore, if our patients had been reclassified according to the presence or absence of CKD, there might have been a difference in the rate of change in eGFR.
There was a tendency for more bleeding in soft coagulation users than in non-users. This results in a longer ischemic time. Since soft coagulation was mainly performed by assistants, differences in experience might have affected whether effective hemostasis could be achieved. According to some reports, bleeding volume is a possible predictor of the rate of change in eGFR (6), and it is possible that it affected the change in eGFR in this study.
This study had some limitations. The results are the outcome of a retrospective study conducted at a single center, and other influences, such as the effect of the era on historical control, must be considered. Despite this limitation, we believe that this study provides clinically valuable evidence suggesting the usefulness of a soft coagulation system.
Conclusions
The use of soft coagulation in RAPN reduces the incidence of RAP. There is no statistically significant difference in terms of changes in eGFR over time. We believe that this report will help reduce the incidence of complications when soft coagulation is used in RAPN in institutions where it is available.
Acknowledgments
We would like to thank Editage (http://www.editage.com) for editing and reviewing this manuscript for English language.
Funding: None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-24-84/rc
Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-84/dss
Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-24-84/prf
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-24-84/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work and ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was approved by the Institutional Review Board of Jichi Medical University Hospital (No. A22-023) and conformed to the provisions of the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from all participants for inclusion in the study.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Capitanio U, Montorsi F. Renal cancer. Lancet 2016;387:894-906. [Crossref] [PubMed]
- DI Trapani E. Pathological High-risk Renal Cell Carcinoma: Trends in Clinical Characteristics Over 25 Years. Anticancer Res 2018;38:4123-30. [Crossref] [PubMed]
- Fujisaki A, Takayama T, Teratani T, et al. Histological and radiological evaluation of thermal denaturation depth using soft coagulation during partial nephrectomy in living pigs. Int J Urol 2021;28:1274-80. [Crossref] [PubMed]
- Tachibana H, Kobari Y, Fukuda H, et al. Higher risk of intraoperative bleeding in right-sided renal tumors compared to left-sided tumors in robot-assisted partial nephrectomy. Asian J Endosc Surg 2023;16:432-40. [Crossref] [PubMed]
- Swavely NR, Anele UA, Porpiglia F, et al. Optimization of renal function preservation during robotic partial nephrectomy. Ther Adv Urol 2019;11:1756287218815819. [Crossref] [PubMed]
- Nakamura M, Kameyama S, Ambe Y, et al. Predictive factors for postoperative renal function after off-clamp, non-renorrhaphy partial nephrectomy. Transl Androl Urol 2022;11:1226-33. [Crossref] [PubMed]
- Takayama T, Fujita A, Sugihara T, et al. Natural history of asymptomatic renal artery pseudoaneurysm after robot-assisted partial nephrectomy. Transl Androl Urol 2021;10:3555-65. [Crossref] [PubMed]
- Kobari Y, Takagi T, Yoshida K, et al. Comparison of postoperative recovery after robot-assisted partial nephrectomy of T1 renal tumors through retroperitoneal or transperitoneal approach: A Japanese single institutional analysis. Int J Urol 2021;28:183-8. [Crossref] [PubMed]
- Ngo TC, Lee JJ, Gonzalgo ML. Renal pseudoaneurysm: an overview. Nat Rev Urol 2010;7:619-25. [Crossref] [PubMed]
- Jain S, Nyirenda T, Yates J, et al. Incidence of renal artery pseudoaneurysm following open and minimally invasive partial nephrectomy: a systematic review and comparative analysis. J Urol 2013;189:1643-8. [Crossref] [PubMed]
- Tohi Y, Murata S, Makita N, et al. Comparison of perioperative outcomes of robot-assisted partial nephrectomy without renorrhaphy: Comparative outcomes of cT1a versus cT1b renal tumors. Int J Urol 2019;26:885-9. [Crossref] [PubMed]
- Tohi Y, Murata S, Makita N, et al. Absence of asymptomatic unruptured renal artery pseudoaneurysm on contrast-enhanced computed tomography after robot-assisted partial nephrectomy without parenchymal renorrhaphy. Asian J Urol 2020;7:24-8. [Crossref] [PubMed]
- Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461-70. [Crossref] [PubMed]
- Singh D, Gill IS. Renal artery pseudoaneurysm following laparoscopic partial nephrectomy. J Urol 2005;174:2256-9. [Crossref] [PubMed]
- Cohenpour M, Strauss S, Gottlieb P, et al. Pseudoaneurysm of the renal artery following partial nephrectomy: imaging findings and coil embolization. Clin Radiol 2007;62:1104-9. [Crossref] [PubMed]
- Scoll BJ, Uzzo RG, Chen DY, et al. Robot-assisted partial nephrectomy: a large single-institutional experience. Urology 2010;75:1328-34. [Crossref] [PubMed]
- Tanagho YS, Kaouk JH, Allaf ME, et al. Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers. Urology 2013;81:573-9. [Crossref] [PubMed]
- Nakamura K, Imamura Y, Yamamoto S, et al. Soft coagulation in robot-assisted partial nephrectomy without renorrhaphy: Comparison with standard suture. Int J Urol 2020;27:352-4. [Crossref] [PubMed]
- Guillotreau J, Yakoubi R, Long JA, et al. Robotic partial nephrectomy for small renal masses in patients with pre-existing chronic kidney disease. Urology 2012;80:845-51. [Crossref] [PubMed]
- Kumar RK, Sammon JD, Kaczmarek BF, et al. Robot-assisted partial nephrectomy in patients with baseline chronic kidney disease: a multi-institutional propensity score-matched analysis. Eur Urol 2014;65:1205-10. [Crossref] [PubMed]
- Martini A, Sfakianos JP, Paulucci DJ, et al. Predicting acute kidney injury after robot-assisted partial nephrectomy: Implications for patient selection and postoperative management. Urol Oncol 2019;37:445-51. [Crossref] [PubMed]
