Preservation Of Parenchyma Research Articles

What Happens to the Preserved Renal Parenchyma After Clamped Partial Nephrectomy?

BackgroundMost partial nephrectomies (PNs) are performed with hilar occlusion to reduce blood loss and optimize visualization. However, the histologic status of the preserved renal parenchyma years after PN is unknown. ObjectiveTo compare the histologic chronic kidney disease (CKD) score of renal parenchyma before and years after PN, and to explore factors associated with CKD-score increase and glomerular filtration rate (GFR) decline. Design, setting, and participantsA retrospective review of 147 renal cell carcinoma patients who underwent PN and subsequent radical nephrectomy (RN) due to tumor recurrence was performed in 19 Chinese centers and Cleveland Clinic. Macroscopic normal renal parenchyma was evaluated at least 5 mm away from the tumor in PN specimens and at remote sites in RN specimens. InterventionPN/RN and ischemia. Outcome measurements and statistical analysisHistologic CKD score (0–12) represents a summary of glomerular/tubular/interstitial/vascular status. Predictive factors for a substantial increase of CKD score (≥3) were evaluated by logistic regression. Results and limitationsSixty-five patients with all necessary data were analyzed. The median interval between PN and RN was 2.4 yr. Median durations of warm ischemia (n = 42) and hypothermia (n = 23) were both 23 min. The histologic CKD score was increased after RN in 47 (72%) patients, with 29 (45%) experiencing more substantial increase (≥3). There was no significant difference in the change of CKD score related to the type and duration of ischemia (p = 0.7 and p = 0.4, respectively) or interval from PN to RN (p > 0.9). However, patients with comorbidities of hypertension, diabetes, and/or pre-existing CKD (hypertension [HTN]/diabetes mellitus [DM]/CKD) demonstrated increased rate and extent of CKD-score increase. On univariate analysis, HTN/DM/CKD was the only predictor of a substantial CKD-score increase (odds ratio: 3.53 [1.12–11.1]). Decline of GFR was modest and similar between patients with/without a substantial CKD-score increase. ConclusionsWithin the context of conventional, limited durations of ischemia, histologic deterioration of preserved parenchyma after PN appears to be primarily due to pre-existing medical comorbidities rather than ischemia. A subsequent decline in renal function was mild and independent of histologic changes. Patient summaryAfter clamped PN, the preserved renal parenchyma demonstrated histologic deterioration in many cases, which correlated with the presence of comorbidities such as hypertension, diabetes mellitus, or chronic kidney disease. In contrast, the type and duration of ischemia did not correlate with histologic changes after PN, suggesting that ischemia insult had only limited impact on parenchyma deterioration.

Comparison Between Minimally-Invasive Right Anterior and Right Posterior Sectionectomy versus Right Hepatectomy: An International Multicenter Propensity-Score Matched and Coarsened-Exact Matched Analysis of 1100 Patients

Introduction: The role of minimally-invasive right anterior and right posterior sectionectomy (MI-RAS/MI-RPS) in right sided liver lesions remains debatable. However technically more demanding, these procedures might result in faster recovery and lower postoperative morbidity compared to minimally-invasive right hemihepatectomy (MI-RH). Methods: This is an international multicenter retrospective analysis of 1114 patients undergoing MI-RH, MI-RAS and MI-RPS at 21 centers between 2006-2019. MIS included pure laparoscopic, robotic or hybrid approach. A propensity matched and coarsened-exact matched analysis was performed. Results: 1100 cases met study criteria of whom 759 underwent laparoscopic, 283 robotic, 11 hand-assisted and 47 laparoscopic-assisted (hybrid surgery). There were 632 RH, 373 RPS and 95 RAS. There were no differences in baseline characteristics after matching. In the MI-RAS/MI-RPS group, median blood loss was higher (400 VS 300ml, p=0.001) as well as intraoperative blood transfusion (19.6% VS 10.7%, p=0.004). However, major morbidity was lower (7.1% VS 14.3%, p=0.007) and the need for reoperation was lower (1.4% VS 4.6%, p=0.029). The rate of close/involved margins was higher in the MI-RAS/MI-RPS group (23.4% VS 8.9%, p<0.001). These findings were consistent after both propensity and coarsened-exact matching. Conclusion: Although technically more demanding, MI-RAS/MI-RPS is a valuable alternative for MI-RH in right sided liver lesions with lower postoperative morbidity, possibly due to the preservation of parenchyma. However, the rate of close/involved margins is higher in these procedures. These findings might guide surgeons in selecting the appropriate procedure for their patients.Tabled 1EP01C-039TotalN = 1100Entire unmatched cohort1:1 Propensity matched cohort1:1 Coarsened-exact matched cohortMI-RA/RPSN = 468MI-RHN = 632P-valueMI-RA/RPSN = 280MI-RHN = 280P-value†MI-RA/RPSN = 188MI-RHN = 188P-value†Median blood loss (IQR), ml300 (200-600)400 (200-750)300 (200-500)0.001400 (200-750)300 (150-500)0.022400 (200-850)300 (120-500)0.001Intraoperative blood transfusion, n (%)169/1100 (15.4%)86/468 (18.4%)83/632 (13.1%)0.01755/280 (19.6%)30/280 (10.7%)0.00439/188 (20.7%)23/188 (12.2%)0.023Pringle maneuver applied, n (%)521/1084 (48.1%)276/466 (59.2%)245/618 (39.6%)<0.001179/278 (64.4%)102/277 (36.8%)<0.001114/187 (61.0%)67/187 (35.8%)<0.001Major morbidity (Clavien-Dindo grade> 2), n (%)129/1100 (11.7%)36/468 (7.7%)93/632 (14.7%)<0.00120/280 (7.1%)40/280 (14.3%)0.00714/188 (7.4%)22/188 (11.7%)0.139Reoperation, n (%)30/1100 (2.7%)5/468 (1.1%)25/632 (4.0%)0.0044/280 (1.4%)13/280 (4.6%)0.0293/188 (1.6%)10/188 (5.3%)0.02830-day mortality, n (%)12/1100 (1.1%)2/468 (0.4%)10/632 (1.6%)0.0682/280 (0.7%)2/280 (0.7%)1.0002/188 (1.1%)1/188 (0.5%)0.571Close/ involved margins (≤1mm) for malignancies, n (%)127/978 (13.0%)75/421 (17.8%)52/557 (9.3%)<0.00157/244 (23.4%)22/247 (8.9%)<0.00140/170 (23.5%)14/170 (8.2%)<0.001*P value in brackets were additionally obtained (as a sensitivity analysis) from mixed-effects negative binomial regression with robust variance, which treats length of stay as a count response, whereby a random-effects term was used to account for the paired data structure. The marginal model was used in the full (unmatched) cohort. The incidence rate ratios in the full cohort, PSM cohort, and CEM cohorts were 0.83 (95% CI 0.75 to 0.91), 0.87 (95% CI 0.77 to 0.98), and 0.85 (95% CI 0.75 to 0.96) respectively, indicating a shorter post-operative stay in the RAS/RPS arm compared to the RH arm.For categorical variables, denominators may differ from total numbers due to missing data Open table in a new tab *P value in brackets were additionally obtained (as a sensitivity analysis) from mixed-effects negative binomial regression with robust variance, which treats length of stay as a count response, whereby a random-effects term was used to account for the paired data structure. The marginal model was used in the full (unmatched) cohort. The incidence rate ratios in the full cohort, PSM cohort, and CEM cohorts were 0.83 (95% CI 0.75 to 0.91), 0.87 (95% CI 0.77 to 0.98), and 0.85 (95% CI 0.75 to 0.96) respectively, indicating a shorter post-operative stay in the RAS/RPS arm compared to the RH arm. For categorical variables, denominators may differ from total numbers due to missing data

Laparoscopic nephron-sparing surgery for the treatment of canine dioctophymosis

This paper reports on two cases of laparoscopic nephrotomy employed in the treatment of canine dioctophymosis, which is considered a unusual procedure and a new treatment proposal heretofore not performed in veterinary medicine. Two patients were treated, one with a history of hematuria and the other with incidental finding of the parasite in the abdominal cavity during elective ovariohysterectomy. Both dogs were subjected to abdominal ultrasound, which produced images indicating the presence of the parasite in the right side kidney, but with partial parenchymal preservation. The patients were therefore subjected to laparoscopic nephrotomy. The surgical procedure was effective in treating dioctophymosis and enabled minimum tissue invasion during surgery, in addition to preservation of the kidney.

Evaluation of the Surgical Margin Threshold for Avoiding Recurrence after Partial Nephrectomy in Patients with Renal Cell Carcinoma.

PurposeAn adequate minimal surgical margin for partial nephrectomy (PN) has not yet been conclusively established. Therefore, we aimed to compare PN recurrence rates according to surgical margin status and to establish an adequate minimal surgical margin.Materials and MethodsWe retrospectively studied patients with clinically localized renal cell carcinoma who underwent PN between 2005 and 2014. Surgical margin width (SMW) was assessed for all surgical tissues and divided into three groups: SMW <1 mm, SMW ≥1 mm, and positive surgical margin (PSM). The data were analyzed using the Kaplan-Meier method with log-rank tests and multivariate Cox regression models.ResultsOf 748 patients (median age, 55 years; interquartile range, 46–64 years; 220 female), 704 (94.2%) and 44 (5.8%) patients had negative and PSMs, respectively. Recurrence-free survival was significantly lower in patients with PSMs (p<0.001) and was not significantly different between SMW ≥1 mm and <1 mm groups (p=0.604). PSM was a significant predictor of recurrence (hazard ratio: 8.03, 95% confidence interval: 2.74–23.56, p<0.001), in contrast to SMW <1 mm (p=0.680).ConclusionA PSM after PN significantly increases the risk of recurrence. We discovered that even a submillimeter safety surgical margin may be enough to prevent recurrence. To maximize normal renal parenchyma preservation and to avoid cancer recurrence in renal parenchymal tumor patients, PN may be a safe treatment, except for those with a PSM in the final pathology.

Carinal resection and reconstruction with complete pulmonary parenchyma preservation: a single-institution analysis of 36 cases.

BackgroundCarinal resection, performed in only a few high-volume centers, remains one of the most complicated and technically demanding surgeries. Few studies have examined the outcomes of carinal resection and reconstruction with complete pulmonary parenchyma preservation.MethodsPatients who underwent isolated carinal resection and reconstruction at the Shanghai Chest Hospital between 2006 and 2020 were retrospectively reviewed. Clinicopathological, perioperative, and follow-up outcomes were analyzed.ResultsA total of 36 patients were included, including 19 men and 17 women. The average age was 50.7±14.8 years. Right posterolateral thoracotomy (n=33, 91.7%) and cross-field intubation during anastomosis (n=31, 86.1%) were selected for the majority of the carinal surgeries. The average intraoperative blood loss was 225.0 mL, and the mean operation duration was 196.1 minutes. Postoperative complications were observed in 14 patients (38.9%), including cicatricial stenosis (n=8, 22.2%), anastomotic fistula (n=3, 8.3%), air leak (n=1, 2.8%), cardiac arrhythmia (n=4, 11.1%), pneumonia (n=2, 5.6%), respiratory failure (n=1, 2.8%), and pulmonary embolism (n=1, 2.8%). There were 2 perioperative deaths (5.6%). Multivariate analysis revealed that being overweight was an independent favorable factor for postoperative complications [P=0.042, odds ratio (OR) =0.092, 95%, confidence interval (CI): 0.009–0.922]. Pathological diagnoses included squamous cell carcinoma (SCC) (n=12, 33.3%), adenoid cystic carcinoma (ACC) (n=15, 41.7%), mucoepidermoid carcinoma (MEC) (n=2, 5.6%), stricture (n=1, 2.8%), and other rare histological types. An R0 resection was achieved in 14 patients, while 21 patients (60.0%) had microscopically positive margins. Lymph node metastasis was confirmed in 6 patients (17.1%). Overall survival (OS) was 94.4% at 1 year and 79.4% at 5 years, with 107 months as the median survival time (95% CI: 64.0–150.0 months). All patients with negative margins remained alive during the follow-up period, while those who received R1 resections had much poorer survival rates due to tumor recurrence [P=0.042, hazard ratio (HR) =4.938, 95% CI: 1.062–22.950].ConclusionsIn selected patients, carinal resection and reconstruction with complete pulmonary parenchyma preservation was a feasible option to achieve an appreciable long-term survival at the risk of acceptable operative mortality and morbidity, particularly when complete resection with negative margins could be realized.

Surgical advances in the management of brain metastases

As the epidemiological and clinical burden of brain metastases continues to grow, advances in neurosurgical care are imperative. From standard magnetic resonance imaging (MRI) sequences to functional neuroimaging, preoperative workups for metastatic disease allow high-resolution detection of lesions and at-risk structures, facilitating safe and effective surgical planning. Minimally invasive neurosurgical approaches, including keyhole craniotomies and tubular retractors, optimize the preservation of normal parenchyma without compromising extent of resection. Supramarginal surgery has pushed the boundaries of achieving complete removal of metastases without recurrence, especially in eloquent regions when paired with intraoperative neuromonitoring. Brachytherapy has highlighted the potential of locally delivering therapeutic agents to the resection cavity with high rates of local control. Neuronavigation has become a cornerstone of operative workflow, while intraoperative ultrasound (iUS) and intraoperative brain mapping generate real-time renderings of the brain unaffected by brain shift. Endoscopes, exoscopes, and fluorescent-guided surgery enable increasingly high-definition visualizations of metastatic lesions that were previously difficult to achieve. Pushed forward by these multidisciplinary innovations, neurosurgery has never been a safer, more effective treatment for patients with brain metastases.

Venovenous extracorporeal membrane oxygenation-assisted tracheobronchial surgery: a retrospective analysis and literature review.

BackgroundAirway management in tracheobronchial surgeries, especially carinal resection and reconstruction, remains one of the greatest challenges to thoracic surgeons. This study investigated the safety and effectiveness of venovenous extracorporeal membrane oxygenation (VV-ECMO) for respiratory support during tracheobronchial surgeries.MethodsThe data of patients who underwent VV-ECMO-assisted tracheobronchial surgeries at the Shanghai Chest Hospital from August 2006 to August 2021 were retrospectively reviewed. The clinicopathological, perioperative, and follow-up outcomes were analyzed.ResultsA total of 7 patients (4 males and 3 females) with a median age of 56 years (range, 11–70 years) were included in the study. The following tracheobronchial surgeries were conducted: carinal resection and reconstruction with complete pulmonary parenchyma preservation (n=4), left main bronchus and hemi-carinal sleeve resection (n=1), right upper sleeve lobectomy and hemi-carinal resection (n=1), and tracheal resection and reconstruction (n=1). The mean time on VV-ECMO was 167.7±65.8 min, and the mean operative time was 192.4±55.0 min. The average estimated blood loss was 271.4±125.4 mL. No perioperative death or reimplantation of VV-ECMO occurred. Postoperative complications were observed in 2 patients, including 1 case of respiratory failure due to preoperative severe chronic obstructive pulmonary disease (COPD) and 1 case of chylothorax. The median hospital stay was 11 days (range, 7–46 days). The median follow-up time was 30 months (range, 21–33 months). All the patients remained alive, and no postoperative readmission occurred during the follow-up period.ConclusionsVV-ECMO is a safe and feasible ventilation mode when intraoperative oxygen saturation cannot be well maintained during tracheobronchial surgery.

Hepatic parenchymal preservation surgery in liver trauma grade IV

Hepatic parenchymal preservation surgery in liver trauma grade IV

V04-05 ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR HIGHLY COMPLEX ENDOPHYTIC TUMOR: A NOVEL RENORRHAPHY CLOSURE

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-05 ROBOT-ASSISTED PARTIAL NEPHRECTOMY FOR HIGHLY COMPLEX ENDOPHYTIC TUMOR: A NOVEL RENORRHAPHY CLOSURE Jennifer Espinales and Firas Petros Jennifer EspinalesJennifer Espinales More articles by this author and Firas PetrosFiras Petros More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Multiple suture techniques have been proposed for renal closure for endophytic tumors during robot-assisted partial nephrectomy (RAPN). There is no consensus for preferred closure technique and this decision is at the discretion of the surgeon. This video demonstrates a novel approach of closure in a completely endophytic, highly complex tumor without the need for bolster. METHODS: A da Vinci Xi Robot was used for RAPN. After using intraoperative ultrasound to aid in tumor identification and define borders of resection, tumor was dissected free from normal parenchyma. Following the resection, a central defect was present over the renal pelvis. Inner renorrhaphy of resection borders was performed with 3-0 V-loc suture. Once the hilar vessels were unclamped, no significant active bleeding was noted from the resection bed. The capsular layer was performed using Weck-renorrhaphy sutures of 2-0 Vicryl suture to close the remaining portion of exposed renal parenchyma in a C-shaped horizontal mattress using sliding-clip renorrhaphy without using bolsters. Tisseel and Fibrillar hemostatic agents were applied to the resection bed and hilum. RESULTS: Surgical outcome revealed warm ischemia time (WIT) was 23 times, estimated blood loss (EBL) was 40 mL, and console time was 160 minutes. Parenchymal preservation was approximately 90%. Pathology showed pT1a clear-cell renal cell carcinoma with negative margins. There were no intraoperative or postoperative complications, and the patient was discharged on post-operative day 1. An 18-month follow-up showed no evidence of recurrence with normal renal function. CONCLUSIONS: RAPN is technically feasible for highly complex endophytic and hilar tumors that would otherwise be managed with radical nephrectomy. For select cases such as our case, we presented a novel renorrhaphy closure with C-shaped horizontal mattress as a valuable-asset for robotic surgeons to achieve an excellent clinical, oncological and functional outcome. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e292-e292 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennifer Espinales More articles by this author Firas Petros More articles by this author Expand All Advertisement PDF downloadLoading ...

Parenchymal preserving liver resection for centrally located liver tumors: how I do it?

Central liver tumors often require extended hepatectomy or a central hepatectomy with complex biliary reconstructions. Extended resections are prone to higher chances of post-operative liver failure, while the resections mandating reconstructions run a risk of biliary leaks. Non-anatomical liver resections for these centrally located tumors provide a benefit of functional parenchymal preservation but a higher perceived risk of oncological inadequacy. This manuscript is an attempt to showcase author's technique of parenchymal sparing liver resection for central located liver tumor without the need for any biliary reconstruction while ensuring oncological adequacy during the conduct of the procedure.

Effects of tobacco smoke inhalation on the morphology and cell proliferation rate in Wistar rats submandibular glands

Cigarette smoke compromises the salivary glands, altering saliva. Cotinine is the most effective biomarker to assess tobacco consumption, and passive smokers are characterized by serum cotinine levels above 2.1 ng/mL. This study aimed to evaluate the effect of exposure to cigarette smoke on rats submandibular glands. The morphology, the proliferative cells of intercalated ducts (immunohistochemistry for KI-67) and its correlation with serum cotinine levels were analyzed. Wistar rats were grouped: control (C); inhalation of smoke for 30 days (T1) and 60 days (T2). Data were analyzed with the Levene variance homogeneity test, Spearman's test, ANOVA and Tukey's post-test, with significance p&lt;0.05. Morphology showed a preserved parenchyma in C, and altered secretory cells in T1 and T2. There was a significant reduction in the number of proliferative cells [ANOVA, F = 4.726; d.f. = 2, 26; p&lt;0.05]: C vsT1 (p&lt;0.05) and C vs T2 (p&lt;0.05). T1 and T2 serum cotinine levels were significantly higher (p&lt;0.05) than C. There was a significant negative correlation [ρ = -0.418, n=27, p&lt;0.05] between serum cotinine levels and the rate of cellular proliferation. These results suggest that of tobacco smoke inhalation has a decreased of the cellular proliferation rate and altered morphology in submandibular glands de ratos Wistar.

Lung sparing left secondary carina resection for low-grade tumors: a single-center study.

Left-side secondary carina resection and reconstruction is a rare, complex procedure, performed just in a few specialized centers in a restricted group of patients. Few studies describe this technique and report its short and long-term results. We reviewed our experience to evaluate the perioperative and short-term outcomes of a very demanding surgery. We retrospectively collected the information of all the patients who underwent secondary carina resection and reconstruction for low-grade malignant bronchial tumors at our center. Between January 2012 and September 2018, 23 patients received surgery for low-grade malignant bronchial tumors. In all patients, a secondary carina resection and reconstruction with total lung parenchymal preservation was performed. The mean age was 44.5 ± 12.2years. Pathologies included adenoid cystic carcinoma in ten patients, carcinoid in 7 (6 typical and 1 atypical), mucoepidermoid carcinoma in 4, myoepithelioma in 1 and inflammatory myofibroblastic tumor in 1. The median length of the resected bronchus was 25mm (range 15-50mm). Three patients (13%) had, at least, one postoperative complication with no deaths. Two patients had lymph node metastases and eight had positive margins. Nine patients received adjuvant therapy. Follow-up ranged from 13 to 96months, all patients are currently alive and free of recurrence. Resection and reconstruction of the left secondary carina with preservation of the lung parenchyma can be performed safely in anatomically and oncologically appropriate patients, providing good short-term results when combined with adjuvant therapies.

Embolization of Giant Post-Traumatic Arteriovenous Renal Fistula using the Penumbra Occlusion Device

Purpose: Giant post-traumatic artero-venous renal fistula is a very rare condition, and the exclusion of renal perfusion is the principal risk of embolization. Aim of our presentation is to evaluate new materials and devices derivated by neuro-angio experience to treat the vascular arterio-venous renal fistula. Material and Methods: From march 2017t to december 2020 we have treated 3 post traumatic hight-flow artero-venous renal fistulas. In one case an aneurysmatic dilatation of renal artery was associated. All patients were previously and during follow-up evaluated by MDCTA and US-color-Doppler. POD Penumbra System plus, POD packing coil were used to treat arterio-venous renal fistula. Results: In all cases (3/3) complete arterio-venous renal fistula occlusion was obtained. Pod System and Pod packing coil were delivered with microcatheter directly in the arterial side of the arterio-venous renal fistula. The renal fuction and complete parenchymal preservation were obtained Conclusions: In our preliminary experience Penumbra System revealed to be a secure device for a complete exclusion of high-flow arterio-venous renal fistula and preserving renal perfusion.

Left secondary carinal resection and reconstruction for low-grade bronchial malignancies.

ObjectivesA rare and complex procedure, total lung sparing left secondary carinal resection and reconstruction is only performed in a few specialized centers in a restricted group of patients. We reviewed our experience to evaluate its safety.MethodsPatients who underwent left secondary carinal resection and reconstruction with complete lung parenchymal preservation for low-grade bronchial malignancies at the Shanghai Chest Hospital and the Padua University Hospital were retrospectively reviewed. Clinicopathologic factors and perioperative outcomes were analyzed.ResultsThirty patients underwent the procedure between July 2012 and July 2019 (mean age, 42.9 years). No operative mortality occurred and postoperative complications developed in 4 patients (13.3%), including pneumonia (n = 3 [10.0%]), subcutaneous emphysema (n = 2 [6.7%]), and prolonged air leak (n = 2 [6.7%]). Pathologies included adenoid cystic carcinoma (n = 11), mucoepidermoid carcinoma (n = 6), carcinoid tumors (n = 9 [8 typical and 1 atypical subtypes]), inflammatory myofibroblastic tumor (n = 3), and myoepithelioma (n = 1). The margins were positive in 8 patients (26.7%), whereas 2 patients (6.7%) had positive lymph nodes. Adjuvant therapies were performed postoperatively, including chemoradiotherapy for positive lymph nodes and radiotherapy for positive margins.ConclusionsTotal lung sparing left secondary carinal resection and reconstruction can be performed safely in well-selected and oncologically appropriate patients with low-grade bronchial malignancies.

“Crush Carving Technique” Using a Soft Coagulation Device: A Simple Method for Successful Laparoscopic Partial Nephrectomy Without Hilar Clamping

Abstract Introduction: According to recent studies, kidney parenchymal volume preservation was significantly associated with ultimate renal function than hilar clamping in partial nephrectomy (PN) ...

Clinical advantages of robot-assisted partial nephrectomy versus laparoscopic partial nephrectomy in terms of global and split renal functions: A propensity score-matched comparative analysis.

To identify predictors of renal function preservation, and to compare the global and split renal function outcomes of robot-assisted partial nephrectomy and laparoscopic partial nephrectomy. Demographic, operative and pathological data, as well as renal function outcomes, of 251 patients who underwent laparoscopic (n=104) and robot-assisted (n=147) partial nephrectomy between 2008 and 2018 were retrospectively analyzed. Propensity score matching (1:1) was carried out to adjust for potential baseline confounders. Functional outcomes were assessed based on the estimated glomerular filtration rate and dynamic renal scintigraphy (using 99m Tc-mercaptoacetyltriglycine), including renal volumetric analysis. A total of 98 patients were allocated to each partial nephrectomy group. Ischemic (laparoscopic vs robot-assisted partial nephrectomy: 29 vs 15min, P<0.001) and operative times (181 vs 100min, P<0.001) were shorter in robot-assisted partial nephrectomy. The preservation ratio of global renal function at 3months (88.3% vs 91.4%, P=0.040) and 12months (87.8% vs 91.5%, P=0.010) postoperatively, and the renal function of the operated kidney (80.3% vs 88.2%, P<0.001) were greater after robot-assisted partial nephrectomy. In robot-assisted partial nephrectomy, the volume of resected parenchyma was significantly smaller (27.2 vs 15.5mL, P<0.001), resulting in greater postoperative normal parenchymal volumes (120 vs 132mL, P<0.001) and a greater parenchymal preservation ratio (81.1% vs 90.1%, P<0.001). The parenchymal preservation ratio was the strongest predictor of renal function preservation after surgery (P<0.001, odds ratio 6.02). Robot-assisted partial nephrectomy allows better preservation of split renal function than laparoscopic partial nephrectomy by increasing the parenchymal preservation ratio. This translates into better postoperative global renal function.

Long-Term Oncologic Outcomes After Laparoscopic and Robotic Tumor Enucleation for Renal Cell Carcinoma.

ObjectivesTumor enucleation (TE) optimizes parenchymal preservation with promising short-term oncologic outcomes compared with standard partial nephrectomy (SPN). However, researches/literatures about long-term oncologic outcomes for TE after minimally invasive surgery are scarce. We aim to analyze long-term oncologic outcomes after laparoscopic and robotic tumor enucleation for renal cell carcinoma (RCC).Patients and MethodsWe retrospectively analyzed 146 patients who underwent TE with either laparoscopic or robotic approach for localized RCC in our center. Local recurrence, cancer specific survival (CSS), recurrence free survival (RFS), and overall survival (OS) were the main outcomes. Survival curves were generated using a Kaplan-Meier method. Perioperative outcomes and pathological outcomes were also analyzed.ResultsOverall, 98 male and 48 female patients were eligible for the study. The median tumor size was 3.4 cm with a median R.E.N.A.L. score of seven. Warm ischemia was used in 143 patients with a median ischemia time of 20 min and three patients had zero ischemia. Five patients (3.4%) had major complications (> Clavien IIIa) and only two were related to urinary system. The median global glomerular filtration rate (GFR) preserved after surgery was 93%. Pseudocapsule invasion was reported in 50 tumors (34%) and positive surgical margins were found in 3/146 (2.1%) tumors. At a median follow-up of 66 months, local recurrence happened in two patients (1.4%), and systemic recurrence happened in six patients (4.2%). The 5-year CSS, RFS, OS were 95.7, 89.6, and 91.9%, and the 10-year CSS, RFS, OS were 93.8, 89.6, and 90.0%, respectively.ConclusionThis study indicates that tumor enucleation with laparoscopic or robotic approach in experienced hands for the treatment of RCC appears oncologically safe with a median follow-up of more than 5 years. Prospective studies with more patients and longer follow-up will be required to further evaluate oncologic safety after TE.

Long term renal function following selective angioembolization for iatrogenic vascular lesions after partial nephrectomy: A matched case-control study.

PurposePartial nephrectomy is associated with a 1%–2% risk of renal iatrogenic vascular lesion (IVL) that are commonly treated with selective angioembolization (SAE). The theoretical advantage of SAE is preservation of renal parenchyma by targeting only the bleeding portion of the kidney. Our study aims to assess the long-term effect of SAE on renal function, especially that this intervention requires potentially nephrotoxic contrast load injection.Materials and MethodsA retrospective review of patients undergoing partial nephrectomy between 2002 and 2018 was performed, and patients who developed IVL were identified. A 1:4 matched case-control analysis was performed. Paired t-test and χ2 test were used for continuous and categorical variables, respectively. Multivariable logistic and Cox proportional hazards regression analyses were used to identify risk factors and confounders for SAE and postoperative renal function.ResultsEighteen patients found to have an IVL after partial nephrectomy were matched with 72 control patients. IVL's were more common in patients after minimally invasive partial nephrectomy (89% vs. 70%, p=0.008) and in those with higher RENAL nephrometry scores (8.8±2.0 vs. 6.5±1.8, p<0.001). On multivariable analysis, lower RENAL scores proved to decrease the odds of requiring postoperative SAE. No significant difference in renal function outcomes was seen at 24 months of follow-up after surgery.ConclusionsSAE for the management of IVL following partial nephrectomy is a safe and efficient procedure with no significant impact on short or long-term renal function. Less complex renal tumors with lower RENAL scores are less likely to require postoperative SAE.

Open partial nephrectomy: current review.

Partial nephrectomy (PN) is increasingly considered the gold standard treatment for localized renal cell carcinomas (RCCs) where technically feasible. The advantage of nephron-sparing surgery lies in preservation of parenchyma and hence renal function. However, this advantage is counterbalanced with increased surgical risk. In recent years with the popularization of minimally invasive partial nephrectomy (laparoscopic and robotic), the contemporary role of open PN (OPN) has changed. OPN has several advantages, particularly in complex patients such as those with a solitary kidney, multi-focal tumors, and significant surgical history, as well as providing improved application of renoprotective measures. As such, it is a technique that remains relevant in current urology practice. In this article we discuss the evidence, indications, operative considerations and surgical technique, along with the role of OPN in contemporary nephron-sparing surgery.

Laparoscopic pyelolithotomy: its current place in the management of renal pelvis stones

Background: Laparoscopic pyelolithotomy is assumed to preserve functional renal parenchyma, and there is a limited risk for immediate or late renal hemorrhage. Therefore, it might be an alternative for the patients in whom maximal preservation of renal parenchyma is necessary. In the present study, we aimed to compare the success rate and perioperative complications of laparoscopic pyelolithotomy. In the present study, we aimed to document and compare the success rate and perioperative complications of laparoscopic pyelolithotomy with published literature about percutaneous nephrolithotomy (PCNL).Methods: We retrospectively reviewed the clinical charts of all patients subjected to laparoscopic pyelolithotomy (18 cases) in the Department of General Surgery at SMIMER Hospital (tertiary care centre), Surat between the period of January 2014 to December 2018. Record of all patients were assessed for demographic profile, co morbidities, routine blood investigations, including RFT, urine cytology and culture sensitivity, specialized investigation as X-ray KUB, USG KUB, IVP/CT-Urography, DTPA scan, all patients were called for follow up evaluation with radiological, clinical and RFT studies at regular intervals upto 3 months.Results: LP is considered a successful alternative therapy for PCNL in selected cases with large renal stones like those in the extra renal pelvis in patients without a history of previous surgery. In addition, laparoscopic pyelolithotomy (LP) can be considered as a reasonable therapeutic option for large staghorn calculus which cannot be removed with a reasonable number of access and sessions of PCNL.Conclusions: Our results show that laparoscopic pyelolithotomy is equally good or better as compared to PCNL in selected cases.