Roboter-assistierte Chirurgie des Nierenzellkarzinoms – heute ein Standard?

Zusammenfassung

Seit der Erstbeschreibung Roboter-assistierter Nierentumoroperationen im Jahr 2001 sind 20 Jahre vergangen, das Verfahren wird aber immer noch nicht flächendeckend in jeder deutschen urologischen Klinik angeboten. Insofern stellt sich die Frage, ob Roboter-assistierte Nierentumoreingriffe heutzutage als Standard angesehen werden können.

Bis heute liegen für die Roboter-assistierte radikale Nephrektomie keine randomisiert-kontrollierten Studien zum Vergleich mit dem offenen oder laparoskopischen Vorgehen vor. Dennoch zeigt sich, dass gegenüber der offenen Nephrektomie sowohl Laparoskopie als auch Robotik insgesamt bessere perioperative Ergebnisse bei vergleichbarem onkologischen Outcome ermöglichen. Im direkten Vergleich beider minimal-invasiver Techniken gibt es keine eindeutigen Unterschiede, und insofern keinen Zusatznutzen für den Roboter, zumal die Operation robotisch meist teurer ist. Die Ausweitung der chirurgischen Indikationsstellung und erste Studien zur Roboter-assistierten Entfernung lokal weit fortgeschrittener Nierenzellkarzinome mit Level III bis IV Tumorthromben in der Vena cava deuten aber an, dass die robotische Nephrektomie insbesondere bei hoch komplexen Operationen dem laparoskopischen Zugang überlegen sein kann.

Auch bezüglich der Roboter-assistierten Nierenteilresektion liegen bis heute keine prospektiv-randomisierten Studien vor. Trotzdem ließ sich bei robotisch wie auch laparoskopisch durchgeführten Nierenteilresektionen binnen weniger Jahre bei ausreichender Erfahrung des Operateurs eine geringere Morbidität gegenüber der offenen Operation feststellen. Im direkten Vergleich von robotischer und laparoskopischer Nierenteilresektion gibt es bisher keinen Konsens. Es zeichnet sich aber die Tendenz ab, dass Roboter-assistierte Eingriffe zusätzliche Vorteile haben, vor allem bei komplexen, endophytischen Tumoren. Dennoch sind bei Vergleichen der verschiedenen Operationsverfahren viele Einflussfaktoren zu berücksichtigen, zu denen insbesondere patienten- und tumorspezifische Faktoren, aber auch die Erfahrung von Operateur, Bed-Side Assistent und die jährliche Klinikfallzahl zählen.

Insofern haben sich Roboter-assistierte Nierentumoroperationen bis heute zu einem sicheren Verfahren mit guten operativen Ergebnissen entwickelt und stellen einen etablierten Standard dar. Die perioperativen Ergebnisse sind denen der offenen Operation überlegen, das onkologische Outcome ist vergleichbar. Auch wenn robotische Eingriffe insbesondere aufgrund der hohen Anschaffungskosten häufig teurer sind als laparoskopische, haben sie das Potential, bei komplexen Operationen bessere Ergebnisse zu erzielen. Durch das Auslaufen des Patentschutzes, Eintreten neuer Hersteller und die Entwicklung neuer Technologien wird der Markt robotischer Chirurgie zukünftig wahrscheinlich starken Veränderungen unterliegen und die Kosten werden voraussichtlich sinken.

Abstract

Twenty years have passed since the first reports on robot-assisted kidney tumor surgery in 2001. However, robotic surgery has not spread to all German urologic departments yet. Hence, one has to question whether robot-assisted kidney tumor surgery can be considered a standard today.

Until now, no prospective randomized controlled trials have compared robot-assisted radical nephrectomy with the open or laparoscopic approach. Regardless, laparoscopy and robotics both have proven better perioperative and comparable oncological outcomes than with open nephrectomy. In direct comparison, robot-assisted nephrectomy has no additional benefits over the laparoscopic approach and is less cost-effective. However, reports on robot-assisted level III or IV vena cava tumor thrombectomies illustrate that robotic surgery can be superior to the laparoscopic approach in highly complex interventions.

Likewise, no prospective randomized controlled trials have analyzed robot-assisted partial nephrectomy yet. When conducted by experienced surgeons, robotic and laparoscopic partial nephrectomies can also have lower morbidity compared to the open approach. No consensus has been reached when directly comparing robotic and laparoscopic partial nephrectomy. However, evidence is increasing that robot-assisted partial nephrectomy can offer additional benefits, especially for the treatment of highly complex endophytic renal tumors. Thereof, head-to-head comparisons are often impacted by patient- and tumor-related factors, as well as the learning curve of the surgeon, bed-side assistant and the annual caseload of the department.

Hence, one has to conclude that robot-assisted kidney tumor surgery has evolved into a standard procedure with good results. The perioperative outcomes of robot-assisted surgery are superior to the open technique at a comparable oncological follow-up. Even if robot-assisted interventions are often more expensive than laparoscopic surgery due to higher costs of acquisition, robotics have the potential to gain superior results especially in very complex tumor surgery. Due to expiring patent protections, new manufacturers and the development of new technologies, the market of robotic surgery will most likely undergo significant changes and its costs will probably decrease within the next years.

Schlüsselwörter

Nierenzellkarzinom - Roboter-assistierte Chirurgie - Nierenteilresektion - Minimal-invasive Chirurgie - Nephrektomie

Keywords

renal cell carcinoma - robot-assisted surgery - robotics - nephrectomy - partial nephrectomy

Publication History

Received: 12 February 2021

Accepted after revision: 22 April 2021

Article published online:
09 June 2021

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