Editorial: From Novick to the NHS – the evolution of minimally-invasive NSS
The publication in this issue of the BJUI by Veeratterapillay et al. [1] of a UK multicentre study in a community setting marks a watershed in the availability and quality of minimally invasive nephron-sparing surgery (NSS) for renal cancer. Such a turning point was predicted almost 17 years ago by Novick [2] when he wrote, ‘minimally invasive modalities of tumour resection or destruction should be reserved for highly select patients and awaits improvements in technology, standardization of technique and long-term outcomes data before they may be completely integrated options’. It appears now that robot-assisted surgery provides such a platform. The present study [1] describes the outcomes of patients treated with robot-assisted partial nephrectomy (RAPN) at four centres in Northern England, and shows very good outcomes within their first 250 cases.
The benefits of NSS have been well described. Indeed, excellent outcomes for PN were described over 20 years ago in carefully selected cases, with benefits including reduced incidence of renal insufficiency compared to radical nephrectomy, which until that time had been viewed as the ‘gold-standard’ for patients with RCC [3]. However, the popularity of PN for small renal masses appeared to decline with the advent of laparoscopy. It became apparent that a minimally invasive approach to radical nephrectomy had the advantage of improved recovery, reduced blood loss with equal cancer control to open nephrectomy [4]. Notwithstanding absolute and relative indications for PN, given the choice between an open PN and a laparoscopic radical nephrectomy, the balance for patients with an elective indication for PN was tipped in favour of a minimally invasive yet radical approach [5]. Techniques for PN were in their infancy, and even in the leading high-volume centres outcomes, including warm ischaemia time (WIT) and positive surgical margin (PSM) rate, failed to match those of open surgery [6].
Fast forward to 2017 with the increasing use of robot-assisted urological surgery carrying the advantages of three-dimensional vision, wristed movement and integrated real-time intraoperative imaging, especially beneficial for procedures such as PN where quick and accurate suturing are essential for a successful outcome. Veeratterapillay et al. [1] present a series of 250 patients from centres in the UK, in which each performs <50 RAPN procedures/year, yet the authors present favourable outcomes overall, with a PSM rate of 7.3%, major complications in 6% and trifecta in 68.4%. An impressive learning curve is seen with improving outcomes over the series, such that in the final 50 cases a trifecta (WIT <25 min, negative surgical margin and absence of complications) was achieved in 82% of cases, with a PSM rate of 2% despite increasing complex nephrometry scores, which compares favourably with larger series from internationally renowned centres [6].
So then, with the results of the present study [1], can we say that Novick’s requirements have been met, and that minimally invasive NSS is now a ‘completely integrated option’? Certainly, with the widespread adoption of robot-assisted surgery, high-quality outcomes are within the grasp of centres other than elite academic institutions. As techniques develop and experience grows robot-assisted surgery can be increasingly offered, even for resection of more complex tumours.
To ensure that minimally invasive NSS is delivered to the highest standards, it will be necessary for providers to ensure both quality assurance and quality control in their processes. The learning curve needs to be minimised with structured teaching and mentoring, and the use of adjuncts such as intraoperative ultrasonography or fluorescence should be a routine part of care.
Centres offering this technique should be mindful of the well documented volume–outcome relationship that appears to be ubiquitous among complex surgical procedures. If centres are performing less than an optimum number of cases, they may consider affiliating themselves with other such centres in networks and forming a joint clinical governance programme, as has been described for robot-assisted radical prostatectomy and which has shown demonstrable improvements in outcomes.
Finally, auditing and reporting of outcomes remains the cornerstone of quality assurance as shown by the introduction of the BAUS complex surgery audit, which is intended to drive standards of care forward. Publications such as that of Veeratterapillay et al. [1] greatly assist in documenting the progress of new techniques and emerging technologies. Increasingly, patients expect transparency from healthcare providers, and with the necessary support processes in place, such initiatives, and the data that they produce will help to further improve the delivery of complex surgery to patients from all areas of our practice.
