An International Delphi Consensus About Tumor Rupture During Robotic Partial Nephrectomy (Researching UnPredictable TUmor RupturE during Robotic Partial Nephrectomy—The RUPTURE Project)

Background and objective: Tumor rupture during robot-assisted partial nephrectomy (RAPN) poses oncological risks, including potential malignant cell spread and recurrence. Despite these risks, standardized guidelines for defining, managing, and assessing risk factors of tumor rupture in RAPN are lacking. This Delphi consensus study aimed to frame the definition, risk factors, and oncological implications of tumor rupture in RAPN, as well as to propose management strategies. Methods: Using a modified Delphi method, a steering committee from multiple urological societies (the RUPTURE project) led a consensus-building study that followed the ACcurate COnsensus Reporting Document (ACCORD) checklist. A panel of international experts participated in a two-phase Delphi survey, rating their agreement with statements on tumor rupture, risk factors, and management in RAPN. Consensus was defined as ≥70% agreement, with unresolved statements discussed in an online meeting and subjected to a second voting round. Key findings and limitations: Thirty-three experts evaluated 58 statements. Consensus was reached on 33% of statements in the first round and 37.5% in the second round. Tumor rupture was defined, with risk factors including larger tumor size, complexity, and endophytic growth patterns. Recommended management strategies focused on minimizing tumor spillage by suctioning—rather than grasping—the cancerous tissue, and promptly securing the specimen in an endobag. Routine conversion to radical nephrectomy was not advised unless unresectable tumor remnants were found. Tumor rupture was not linked to distant metastasis, although its oncological impact varied by the rupture extent (ie, gross rupture vs focal; tumor spilled out macroscopically completely removed vs not). Conclusions and clinical implications: This consensus forms a basis for future research on tumor rupture in RAPN, emphasizing standardized definitions and uniform management strategies. Empirical validation through future clinical research is warranted. Patient summary: This research looks at tumor rupture during robotic kidney surgery, which can happen but is rare. The study involved a panel of experts who discussed finding a consensus on when it is more likely to occur and how to manage it effectively to reduce risks. It was also emphasized that while a rupture may not always lead to cancer spreading, the impact on a patient's health can vary and is yet to be determined.