Surgical approach for partial nephrectomy in the management of small renal masses: a systematic review and network meta-analysis.

Background A variety of surgical and non-surgical management options for small renal masses (SRMs) now exist. Surgery, in the form of partial nephrectomy (PN) has three different approaches. It is unclear which partial nephrectomy approach, if any, offers superior clinical outcomes. Aim To compare outcomes in patients with SRMs less than 4cm undergoing PN via open (OPN), laparoscopic (LPN) or robotic (RPN) approach, and to establish the advantages and disadvantages of the various approaches. Methods A systematic literature search in line with PRISMA guidelines was conducted for studies comparing at least two of the above techniques. 18 studies and 17,013 patients were included in our study. A network meta-analysis with a frequentist framework was performed, with OPN as the baseline comparator. The pre-specified primary outcome was R0 resection rates. Secondary outcomes included operating time, ischaemia time, blood loss, transfusion rates, urine leak rates, significant morbidity, length of stay and recurrence. Results There was no significant difference between the techniques in terms of R0 rates, tumour recurrence, urine leak rates, renal function and >3a Clavien-Dindo complications. LPN had a longer ischaemic time and operating time. OPN had a longer length of stay and higher average intraoperative blood loss. RPN had lower blood transfusion rates. Discussion All approaches are acceptable from an oncological perspective. The minimally invasive approaches (i.e., RPN and LPN) offer advantages in terms of morbidity; however, LPN may increase ischaemic time and operative duration. Variations between perioperative outcomes may influence choice of approach on a case-by-case and institutional basis.