Biophotonics-Intraoperative Guidance During Partial Nephrectomy: A Systematic Review and Meta-analysis

Context: Partial nephrectomy (PN) with intraoperative guidance by biophotonics has the potential to improve surgical outcomes due to higher precision. However, its value remains unclear since high-level evidence is lacking. Objective: To provide a comprehensive analysis of biophotonic techniques used for intraoperative real-time assistance during PN. Evidence acquisition: We performed a comprehensive database search based on the PICO criteria, including studies published before October 2022. Two independent reviewers screened the titles and abstracts followed by full-text screening of eligible studies. For a quantitative analysis, a meta-analysis was conducted. Evidence synthesis: In total, 35 studies were identified for the qualitative analysis, including 27 studies on near-infrared fluorescence (NIRF) imaging using indocyanine green, four studies on hyperspectral imaging, two studies on folate-targeted molecular imaging, and one study each on optical coherence tomography and 5-aminolevulinic acid. The meta-analysis investigated seven studies on selective arterial clamping using NIRF. There was a significantly shorter warm ischemia time in the NIRF-PN group (mean difference [MD]: -2.9; 95% confidence interval [CI]: -5.6, -0.1; p = 0.04). No differences were noted regarding transfusions (odds ratio [OR]: 0.5; 95% CI: 0.2, 1.7; p = 0.27), positive surgical margins (OR: 0.7; 95% CI: 0.2, 2.0; p = 0.46), or major complications (OR: 0.4; 95% CI: 0.1, 1.2; p = 0.08). In the NIRF-PN group, functional results were favorable at short-term follow-up (MD of glomerular filtration rate decline: 7.6; 95% CI: 4.6, 10.5; p < 0.01), but leveled off at long-term follow-up (MD: 7.0; 95% CI: -2.8, 16.9;p = 0.16). Remarkably, these findings were not confirmed by the included randomized controlled trial. Conclusions: Biophotonics comprises a heterogeneous group of imaging modalities that serve intraoperative decision-making and guidance. Implementation into clinical practice and cost effectiveness are the limitations that should be addressed by future research. Patient summary: We reviewed the application of biophotonics during partial removal of the kidney in patients with kidney cancer. Our results suggest that these techniques support the surgeon in successfully performing the challenging steps of the procedure. (c) 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.