Abstract
Partial nephrectomy (PN) is the standard procedure for most patients with localized renal cancer. Laparoscopy has become the preferred surgical approach to target this cancer, but the steep learning curve with laparoscopic PN (LPN) remains a concern. In LPN intracorporeal suturing, the operation time is further extended even under robot assistance, a step which prolongs warm ischemic time. Herein, we shared our experience to reduce the warm ischemia time, which allows surgeons to perform LPN more easily by using a combination of hemostatic agents to safely control parenchymal bleeding. Between 2015 and 2018, we enrolled 52 patients who underwent LPN in our hospital. Single-site sutureless LPN and traditional suture methods were performed in 33 and 19 patients, respectively. Preoperative, intra-operative, and postoperative variables were recorded. Renal function was evaluated by estimated glomerular filtration rate (eGFR) pre- and postoperatively. The average warm ischemia time (sutureless vs. suture group; 11.8 ± 3.9 vs. 21.2 ± 7.2 min, p < 0.001) and the operation time (167.9 ± 37.5 vs. 193.7 ± 42.5 min, p = 0.035) were significantly shorter in the sutureless group. In the sutureless group, only 2 patients suffered from massive urinary leakage (>200 mL/day) from the Jackson Pratt drainage tube, but the leakage spontaneously decreased within 7 days after surgery. eGFR and serum hemoglobin were not found to be significantly different pre- and postoperatively. All tumors were removed without a positive surgical margin. All patients were alive without recurrent tumors at mean postoperative follow-ups of 29.3 ± 12.2 months. Single-site sutureless LPN is a feasible surgical method for most patients with small exophytic renal cancer with excellent cosmetic results without affecting oncological results.
Highlights
In 2009, the American Urological Association (AUA) [1] recommended partial nephrectomy (PN) as the reference standard treatment for most clinical T1 renal masses, even in individuals with a normal contralateral kidney, due to its similar efficacy to radical nephrectomy while preserving kidney tissue
A review of nephrectomy records submitted as part of the American Board of Urology surgeon certification/recertification process revealed that the use of PN has increased from 25% to 39% in all nephrectomies [2]
Because it is difficult to achieve renal hypothermia during laparoscopic partial nephrectomy (LPN), it is important to reduce the warm ischemia time, which is understood to correlate with subsequent return of renal function [6]
Summary
In 2009, the American Urological Association (AUA) [1] recommended partial nephrectomy (PN) as the reference standard treatment for most clinical T1 renal masses, even in individuals with a normal contralateral kidney, due to its similar efficacy to radical nephrectomy while preserving kidney tissue. Though no randomized controlled studies have compared the safety and oncological outcomes in terms of renal function and surgical margins, the steep learning curve with laparoscopic partial nephrectomy (LPN) remains a concern [4]. LPN is a technically demanding procedure, even under robotic assistance. Several important challenges, such as preventing perioperative bleeding, reaching hyperthermia after renal artery clamping, reducing warm ischemia time, and performing laparoscopic intracorporeal suturing, must be met during the operation. Because it is difficult to achieve renal hypothermia during LPN, it is important to reduce the warm ischemia time, which is understood to correlate with subsequent return of renal function [6]. Traditional clamping procedures require a significant warm ischemia time during the suturing process. The rigid instrumentation and the need for adaptation to the existing platform make the widespread use of these single- site surgeries difficult
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