Technique Of Partial Nephrectomy Research Articles

Robotic Unclamped “Minimal-margin” Partial Nephrectomy: Ongoing Refinement of the Anatomic Zero-ischemia Concept

BackgroundAnatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia. ObjectiveTo report the technical feasibility of completely unclamped “minimal-margin” robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data. Design, setting, and participantsThis study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49). Surgical procedurePatients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy. Outcome measurements and statistical analysisPrimary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes. Results and limitationsDemographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up. ConclusionsWe developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up. Patient summaryThe technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions.

Robotic Partial and Radical Nephrectomy in Renal Allograft: Demonstration of Technique

Introduction: Renal tumors in allografts are rare but a serious condition. It presents a challenging clinical scenario where proper radiologic evaluation is commonly hindered by the suboptimal renal function. When surgical intervention is indicated, nephron sparing approaches are confronted with a risk of metastasis in an immunocompromised host, whereas graft nephrectomy results in significant postoperative morbidity and mortality as dialysis is reinitiated. Regardless of the surgical plan, graft surgery can be associated with significant vascular morbidities secondary to the dense desmoplastic reaction surrounding the anastomotic areas. Robotic surgery allows meticulous anastomotic dissection due to benefits of magnification, three-dimensional vision, and enhanced seven degrees of freedom of the robotic instruments. This may increase the chances of graft preservation. Moreover, it offers the benefits of minimally invasive surgery with less pain, shorter hospitalization, and less blood loss if total graft nephrectomy is desired. Methods: In this video, we are describing our technique of both robotic partial and total graft nephrectomy in a patient who was found to have a 1.4 cm allograft mass. The patient is a recipient of an extended criteria cadaveric kidney transplant 3 years before presentation. Evaluation was triggered by the fact that the recipient of the contralateral cadaveric kidney developed donor-derived squamous cell carcinoma originating from the allograft. Results: In this video, we demonstrated the key steps in the procedure, which included early control of the external iliac artery, release of the desmoplastic reaction around the transplanted vessels, vascular pedicle control, lysis of adhesions between the kidney and anterior abdominal wall, ultrasound-guided tumor excision, and renorrhaphy. Finally, the frozen section of the partial nephrectomy specimen revealed squamous cell cancer with negative margin. However, we felt that a radical nephrectomy was clinically indicated. Final pathology revealed T3 squamous cell carcinoma. Conclusion: Robotic approach may play a role in partial and the more commonly performed graft nephrectomy. It may provide an opportunity for better vascular dissection and offer the patient a minimally invasive approach to this challenging procedure. No competing financial interests exist. Runtime of video: 8 mins

Mini-flank supra-12th rib incision for open partial nephrectomy for renal tumor with RENAL nephrometry score ≥10: an innovation of traditional open surgery.

The skill of supra-12th rib mini-flank approach for open partial nephrectomy (MI-OPN) provides an advanced operative method for renal tumor. Compared with laparoscopic and robotic surgery, it may be a feasible selection for the complex renal tumors. We describe our techniques and results of MI-OPN in complex renal tumors with high RENAL nephrometry score (RENAL nephrometry score ≥10).Fifty-five patients diagnosed with renal tumors between January 2009 and July 2013 were included in this study. Eligibility criteria comprised of patients with complex renal tumor (RENAL score ≥10) being candidates for partial nephrectomy (PN). All patients received MI-OPN and all surgeries were performed by a single urologist. The preoperative workup comprised of medical history, physical examination, and routine laboratory tests. Serum creatinine was recorded preoperatively and 2 to 3 months after operation. Operative time, ischemia time, blood loss, operative and postoperative complications, renal function, and pathology parameters were recorded.MI-OPN was successfully performed in all cases. Mean tumor size was 4.7 cm (range: 2.5–8.1). Mean warm ischemia time was 28.1 minutes (range: 21–39), mean operative time was 105minutes (range: 70–150) and mean estimated blood loss was 68 mL (range: 10–400). Mean postoperative hospital stay was 6.5 days (range: 5–12). Postoperative complications were found in 3 patients (5.5%). The mean pre- and postoperative serum creatinine levels were 76.2 μmol/L (range: 47–132) and 87.1 μmol/L (range: 61–189) with significant difference (P = 0.004). The mean pre- and postoperative estimated glomerular filtration rate (eGFR) were 91.5 (range: 34–133) and 82.5 (range: 22–126.5), respectively with significant difference (P = 0.024). In an average follow-up of 19.9 months (range: 8–50), no local recurrence or systemic progression occurred.In conclusion, MI-OPN can combine the benefits of both minimal invasive and traditional open partial nephrectomy (OPN) techniques with a smaller incision. It is an innovation of traditional OPN and suitable for the complex renal tumors with high RENAL nephrometry score safely and effectively.

Novel Hat–Spherical partial nephrectomy for localized kidney cancer treatment

Objective To present a novel Model for partial nephrectomy and evaluate its oncological, functional outcomes and complication risks in the application for localized kidney cancer treatment. Methods Two hundred and ten patients with localized kidney cancer underwent open or laparoscopic Hat–Spherical partial nephrectomy from Mar. 2011 to Dec. 2013, and were included for this retrospective analysis. Of the 210 patients, 145 were males and 65 were females. The age ranged from 25 to 78 (56±12) years. The tumor greatest dimension was ≤4.0 cm in 143 cases (68.1%), 4.1–7.0 cm in 49 cases (23.3%) and >7.0 cm in 18 patients (8.6%). According to PADUA (Preoperative Aspects and Dimensions Used for an Anatomical) classification, 90, 86 and 34 patients were respectively stratified as low– (42.9%), intermediate– (40.9%) and high–risk (16.1%) groups. In contrast to traditional technique, the key points of Hat–Spherical partial nephrectomy were as follows: after clamping, the renal capsule was incised sharply 3–5 mm away from the tumor edge, and the incision plane was wedge–shaped and towards the tumor pseudocapsule. The transition between pseudocapsule and normal renal parenchyma was the ideal surgical plane. When reached, the tumor was bluntly separated from the surrounding parenchyma following the natural plane. When close the bottom or approaching the renal sinus, the tumor was enucleated along the pseudocapsule. The positive surgical margin rate, warm ischemic time, complication rate and the postoperative eGFR decline were evaluated. The criteria, in which the 3 key outcomes of negative cancer margin, minimal renal functional decrease and no urological complications, were applied to evaluate the Hat–Spherical partial nephrectomy technique. Results Ninety–two patients underwent open Hat–Spherical partial nephrectomy. The mean operation time was 120±45 min, the mean warm ischemic time was 15±5 min. The estimated blood loss was 246±188 ml. Twenty–two patients (23.9%) needed renal calyceal repairing. One hundred and eighteen patients underwent laparoscopic Hat–Spherical partial nephrectomy. The mean operation time and warm ischemic time were 145±50 min and 23±7 min, respectively. The mean estimated blood loss was 185±120 ml and 30 patients (25.4%) needed renal calyceal repairing. The rate of positive surgical margin was 0.95% (2/210). A total of 42 patients (20.0%) experienced complications during 30 days postoperatively, including 36 ClavienⅠ–Ⅱ minor complications and 6 cases of Clavien Ⅲ–Ⅳ major complications. There were 6 postoperative bleeding events (2.9%) and 4 urine leakages (1.9%). There was no perioperative death. The median (range) follow–up was 18 (10–38) mon. The mean decrease in postoperative eGFR was 9.8±20.4 ml/(min· 1.73 m2), and 62 patients had a greater than 10% reduction in the actual vs volume predicted postoperative eGFR. Until the last follow–up, there was no local recurrence and distant metastasis. Trifecta outcome was achieved in 85 patients (40.5%). Conclusions The Hat–Spherical partial nephrectomy has three main technical advantages, including safely keeping negative surgical margin, maximal preservation of renal parenchyma and reducing the risk of vessel and renal calyceal injury. The superiority of Hat–Spherical technique over traditional partial nephrectomy needs further validation by prospective comparative clinical trials. Key words: Kidney cancer; Hat–Spherical partial nephrectomy; Transition zone

Anatomic partial nephrectomy: technique evolution.

Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function. Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating 'under-the-gun' time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume. Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.

Open partial nephrectomy with modified technique: Comparison to results from contemporary laparoscopic series.

473 Background: To evaluate the surgical and oncological outcome of patients undergoing a modified procedure of open partial nephrectomy which was done with a new technique leaving out selective suturation of renal calices and vessels. Methods: We analyzed 120 consecutive open partial nephrectomies (2005-2010) which were performed with a modified technique at a mid-volume center. This technique included the use of an absorbable non-woven textile consisting of polyglycolic acid, extra-large needles and argon plasma coagulation. The surgical and oncological outcome was evaluated by statistical analysis of the medical records. Results: The mean patient age was 62.8 years (52.6% male). Mean pathological tumor size was 3.0 cm (± 1.4 cm), 53.3% of the tumors were renal cell carcinoma. The mean operative time was 101.7 minutes (±33.6 min) and the mean blood loss was 283.9 ml (±368.5 ml). Ischemia was performed in 23.1% with a mean warm ischemia time of 13.3 minutes ( ± 6.4 min). The operative complication rate was 1.7 %. Topical hemostatic agents were used in 20.2 %. The most frequent postoperative complications were bleeding (5%), pleural effusion (4.2%), urinoma (2.5%), pneumonia (2.5%), wound infection (2.5%) and acute renal failure (2.5%). Five-year cancer specific survival rate was 94.1%. Conclusions: The modified technique of open partial nephrectomy can be performed with high surgical and oncologic safety. Duration of the procedure and ischemia time are short. Due to the rare use of hemostatic agents, the costs can be reduced. Open partial nephrectomy with this technique achieve better results than reported from contemporary reported laparoscopic series, especially regarding warm ischemia and time needed for surgery.

Early Experience in Da Vinci Robot-Assisted Partial Nephrectomy: An Australian Single Centre Series.

Introduction and Objectives. To demonstrate the safety and efficacy of the robot-assisted partial nephrectomy (RAPN) technique in an Australian setting. Methods. Between November 2010 and July 2014, a total of 76 patients underwent 77 RAPN procedures using the Da Vinci Surgical System© at our institution. 58 of these procedures were performed primarily by the senior author (PB) and are described in this case series. Results. Median operative time was 4 hours (range 1.5–6) and median warm ischaemic time (WIT) was 8 minutes (range 0–30) including 11 cases with zero ischaemic time. All surgical margins were clear with the exception of one patient who had egress of intravascular microscopic tumour outside the capsule to the point of the resection margin. Complications were identified in 9 patients (15.8%). Major complications included conversion to open surgery due to significant venous bleeding (n = 1), reperfusion injury (n = 1), gluteal compartment syndrome (n = 1), DVT/PE (n = 1), and readmission for haematuria (n = 1). Conclusion. This series demonstrates the safety and efficacy of the RAPN technique in an Australian setting when performed by experienced laparoscopic surgeons in a dedicated high volume robotic centre.

Application of "arch window" technique in retroperitoneoscopic partial nephrectomy

Objective To investigate the feasibility of the technique in retroperitoneoscopic partial nephrectomy.Methods The technique was performed on 128 renal carcinoma patients receiving retroperitoneoscopic partial nephrectomy between June 2012 and June 2014.There were 76 males and 52 females,with age ranging between 31-76 (average 54).The tumors were all at T1N0M0 stage of American Joint Committee on Cancer (AJCC) with diameters of 0.8-6.2 cm (average 2.6 cm) and located in the upper pole,middle,and lower pole of the kidney in 65,31 and 32 cases respectively.Medical data were collected and compared with the same practice performed without using arch window technique from April 2010 to May 2012.Results All 128 operations were successful without conversion to open surgery.There were no serious intraoperative complications such as damaged large blood vessels or adjacent organs.Thirteen patients had postoperative complications,including 8 cases of hematuresis,2 cases of subcutaneous emphysema and 3 cases of delayed healing.Three hematuria patients recovered after conservative treatment.The operation time was 55-186 min (average 89 min),and blood loss was 30-220 ml (average 60 ml).No patient needed intraoperative blood transfusion.The average renal artery occlusion time was 22 min (14-35 min).Pathological examination reported 106 renal clear cell carcinomas and 1 papillary carcinoma with negative margin; and 21 renal angiomyolipomas.Patients were followed up for 1-25 months post-operation (average 18 months).There was no tumor recurrence or distant metastasis and renal functions were normal.Arch window group had significantly shorter suture time,operation time and renal warm ischemia time,and less intraoperative bleeding than non-arch window group.Conclusion The use of technique in retroperitoneoscopic partial nephrectomy is safe and feasible.It benefits from sufficient surgery field exposure and convenient operation and is worthy of wider clinical application. Key words: Retroperitoneoscopy ; Partial nephrectomy

Nephrometry scoring systems for surgical decision-making in nephron-sparing surgery.

Herein, we review the various recently published nephrometry scoring systems and the available data on their ability to predict clinical outcomes and their usefulness for new operative techniques. Several studies showed that the preoperative aspects and dimensions used for anatomical classification score, the RENAL system, and the centrality index are reproducible and able to predict certain clinical intraoperative and postoperative variables in patients undergoing nephron-sparing surgery. Addition of variables, such as the BMI, to the pre-existing scores might improve their predictive abilities. Nephrometry scoring systems may allow better preoperative planning and counseling of patients. If they gain widespread use in clinical practice, they may also help to give reliable comparisons of morbidity rates among different partial nephrectomy techniques, individual surgeons, and institutions.

Intracorporeal Cooling and Extraction Technique of Robotic Partial Nephrectomy

Abstract Introduction: The ability to ice the kidney and grossly evaluate the excised tumor during open partial nephrectomy has been difficult to replicate in a reliable fashion using a minimally invasive approach. We previously described a robotic partial nephrectomy (RPN) technique with intracorporeal cooling and extraction (I.C.E.) for cold ischemia and intraoperative tumor assessment.1 We present a video of our I.C.E. technique.2 Recent evidence suggests a potential benefit of cold ischemia for preserving renal function.3,4 The total run time for our video is 8 minutes 2 seconds. Materials and Methods: A total of eight patients underwent the I.C.E. modification of RPN by transperitoneal (n=6) and retroperitoneal (n=2) approaches. A GelPOINT® access port (Applied Medical) was used for the camera and assistant ports. After hilar clamping, modified syringes loaded with ice slush were introduced through the GelPOINT and ice slush was applied over the kidney surface. The excised tumor was immediately extra...

Technique and Outcomes of Robot-assisted Retroperitoneoscopic Partial Nephrectomy: A Multicenter Study

BackgroundRobot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN. ObjectiveTo demonstrate RARPN technique and outcomes. Design, setting, and participantsA retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013. Surgical procedureRARPN. Outcome measurements and statistical analysisWe assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS). Results and limitationsThe median age was 60 yr (interquartile range [IQR]: 52–66), and the median body mass index (BMI) was 28.2kg/m2 (IQR: 25.6–32.6). Median maximum tumor diameter was 2.3cm (IQR: 1.7–3.1). Median OT and WIT were 165min (IQR: 134–200) and 19min (IQR: 16–24), respectively; median EBL was 75ml (IQR: 50–150), and median LOS was 2 d (IQR: 1–3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31–10.27; p=0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84±2.14; p=0.025). Higher surgeon volume was associated with shorter WIT (PE: −0.06±0.02; p=0.002). Higher BMI was associated with longer OT (PE: 2.09±0.56; p<0.001). Longer OT was associated with longer LOS (PE: 0.01±0.01; p=0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5±10.3; p=0.075). ConclusionsRARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT. Patient summaryRobot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.

Editorial Comment to Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: Single‐surgeon series

Editorial Comment to Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: Single‐surgeon series

Early experience and operative technique of robotic-assisted partial nephrectomy.

The adoption of robotic-assisted partial nephrectomy (RAPN) is increasing in Australia; however, to date no Australian RAPN series has been reported. This paper describes a single-surgeon initial experience with RAPN and evaluates perioperative, pathological and oncological outcomes. Data on the first 50 consecutive patients to undergo RAPN by a single surgeon were reviewed. Demographic, perioperative, tumour characteristics and Clavien complications were collected in addition to oncological follow-up and renal function monitoring. Mean age was 58.2 ± 10.4 years, body mass index was 28.8 ± 4.5 kg/m(2) and Charlson Co-morbidity Index was 4.6 ± 1.2. Tumour diameter was 31 ± 13 mm and RENAL score was 6.8 ± 1.5. Average total operative time was 151 ± 32.7 min, estimated blood loss was 171.1 ± 185.8 mL, warm ischaemia time was 17.8 ± 6.7 min and length of hospital stay was 3 ± 0.9 days. There were seven Clavien complications and no deaths. Estimated glomerular filtration rate did not decrease significantly post-operatively (P = 0.8); and there was 14.6% upstaging of chronic kidney disease scoring although no patient required dialysis. There were no positive malignant surgical margins, and to date no patient has evidence of disease recurrence. Of 50 patients, 54% had a minimum follow-up of 6 months and 28% had a minimum follow-up of 1 year. We report the largest RAPN study in Australia or New Zealand to date. Initial results suggest that RAPN can be safely introduced into the Australian public and private health systems, and has been effective in oncologic control and renal function preservation.

MP59-14 CLINICAL VALUES OF ZERO ISCHEMIA TECHNIQUE IN PARTIAL NEPHRECTOMY: POSTOPERATIVE FUNCTIONAL PRESERVATION AND WIDE INDICATION FOR TUMOR COMPLEXITY.

MP59-14 CLINICAL VALUES OF ZERO ISCHEMIA TECHNIQUE IN PARTIAL NEPHRECTOMY: POSTOPERATIVE FUNCTIONAL PRESERVATION AND WIDE INDICATION FOR TUMOR COMPLEXITY.

Educational Exhibit Abstract No. 459 - Imaging and treatment of delayed hemorrhagic complications of robotic assisted laparoscopic partial nephrectomies

Understand the surgical technique of robotic assisted laparoscopic partial nephrectomy (RALPN) with attention to impact on adjacent vascular structures. Review the imaging findings of delayed hemorrhagic complications of RALPN. Understand a proposed imaging and treatment algorithm for patients presenting with delayed hemorrhage.

Mini-Flank Supra-12th Rib Incision for Open Partial Nephrectomy Compared with Laparoscopic Partial Nephrectomy and Traditional Open Partial Nephrectomy

PurposeThe purpose of this study was to report our approach of partial nephrectomy (PN) using a supra-12th rib mini-flank incision. We compared mini-incision open partial nephrectomy (MI-OPN) with open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to verify whether MI-OPN can be an alternative to OPN and LPN.MethodsThis was a retrospective single-center study including 194 patients who underwent partial nephrectomy (PN) between February 2005 and December 2010. Demographic, perioperative, and complication data were compared among the MI-OPN group, OPN group and LPN group.ResultsNo statistical differences were reported in either group for age, sex, BMI, tumour side (right or left kidney), RENAL nephrometry scores, PADUA score and preoperative eGFR. The operative time was longer in LPN group when compared with MI-OPN and OPN group (all P<0.001). The warm ischemia time of LPN group was longer than MI-OPN group (P = 0.032) and OPN group (P = 0.005). The length of stay of LPN group was shorter than OPN group (P = 0.018), but was similar to MI-OPN group (P = 0.094). The incidence of renal artery clamping was lower in OPN group when compared with MI-OPN and LPN group (all P<0.001). More estimated blood loss was found in OPN group when compared with MI-OPN group (p = 0.003) and LPN group (P = 0.014). The overall incidence of postoperative complications was similar.ConclusionsThe approach of MI-OPN can couple the benefits of both minimally invasive and open partial nephrectomy techniques with less estimated blood loss, shorter operative time, shorter length of stay, less postoperative complications, and a smaller incision. MI-OPN may be an effective alternative to laparoscopic or traditional open approaches, which maybe more suitable for the tumors with high RENAL nephrometry score or PADUA score.

Robotic Partial Nephrectomy with Superselective Versus Main Artery Clamping: A Retrospective Comparison

BackgroundConcerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery. ObjectiveCompare the perioperative outcomes of superselective versus main renal artery control during robotic PN. Design, setting, and participantsA retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63). InterventionGroup 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia. Outcome measurements and statistical analysisPerioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used. Results and limitationsAll robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up. ConclusionsRobotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies. Patient summaryPreserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.

Comparison of two different renorrhaphy techniques in retroperitoneal laparoscopic partial nephrectomy for complex tumor

Background Partial nephrectomy is currently the standard treatment for clinical T1 renal neoplasms, as it can provide oncologic outcomes equivalent to radical nephrectomy. The aim was to evaluate the efficacy of self-retaining suture (SRS) in renorrhaphy technique in retroperitoneal laparoscopic partial nephrectomy (LPN) for a single renal mass of moderate or high complexity by assessing peri-operative outcomes. Methods A retrospective analysis was done of 64 patients between 2010 and 2012 for complex renal mass (RENAL score ≥7) in whom retroperitoneal LPN was performed with two layers using continuous knotless barbed suture (Quill PDO SRS group; n=34) and absorbable vicryl (non-SRS group; n=30), respectively. Cases were matched for RENAL score. All the surgical procedures were performed by the same surgeon with experience of more than 500 cases of LPN. Comparisons were made in patients and preoperative outcomes and peri-operative complications between SRS group and non-SRS group. Results Mean warm ischemia time (WIT) in SRS group was less than non-SRS group (18.0 vs. 24.8 minutes, P=0.021). Renorrhaphy suture cost in SRS group was lower than non-SRS group ($269.6 vs. $335.8, P=0.001). There were no significant differences between the two groups for postoperative changes in creatinine and estimated glomerular filtration rate and the rate of peri-operative complications. Conclusion SRS was safe for complex renal tumor with two layers, continuous and unknot suture, during LPN and would reduce the WIT and renorrhaphy suture cost significantly.

Conventional laparoscopy and da Vinci robot-assisted technique for partial nephrectomy: comparison of indications and clinical outcomes

Objective To investigate the clinical benefits and role of robot-assisted laparoscopic partial nephrectomy(RAPN) by comparing the clinical data of patients receiving the RAPN or conventional laparoscopic partial nephrectomy(CLPN).MethodsA retrospective analysis was performed for 67 patients who underwent either RAPN(n =24) or CLPN (n =43) between January 2011 and December 2012 at our institution.Preoperative clinical stages of both groups were T1N0M0.Univariate analysis and logistic regression model were used to detect factors affecting indication selection in RAPN.The intraoperative parameters and postoperative outcomes were compared between RAPN and CLPN groups matched for DAP score.ResultsUnivariate and multivariate logistic regression analysis revealed that DAP score(β =1.987,P =0.022,95%CI[1.34,39.79]) was the only predictor of RAPN approach in logistic regression analysis.Only 38 DAP matched cases in RAPN(n =19) and CLPN(n =19) were included for analysis,and the demographics were comparable between the matched two groups except for the preoperative estimated glomerular filtration rate(eGFR).One open conversion was required in the RAPN group due to intra-operation bleeding,and all the cases were smoothly completed in the conventional laparoscopic group.There were no significant differences between the matched two groups regarding the estimated blood loss,time off oral-intake,highest visual analog pain scale,length of stay,complication rate or transfusion rate(all P 0.05).Patients undergoing RAPN had a significantly shorter warm ischemia time([27.0±5.3] min vs [34.2±7.3] min,P 0.05) and a longer operative time([249.5±49.6] min vs [212.9±57.11] min,P 0.05) compared with CLPN group.The surgical margins were negative in both groups.During a mean follow-up of(5.6±2.2) months and(6.6±2.6) months,only one tumor recurrence was notice in the CLPN group.At the last follow-up,the decrease percentage of eGFR was(12±8)% in the RAPN group versus(17±15)% in the CLPN group(P 0.05).ConclusionRAPN requires a shorter warm ischemia time and provides a more rapid learning curve,good surgical safety and good short-term efficacy.For surgeons with experienced CLPN technique,they can use RAPN to treat high-complexity tumors which are beyond the conventional laparoscopic technique.

Robot‐assisted partial nephrectomy vs laparoscopic cryoablation for the small renal mass: redefining the minimally invasive ‘gold standard’

To identify differences between the ablative and extirpative minimally invasive techniques of laparoscopic cryoablation (LC) and robot-assisted laparoscopic partial nephrectomy (RPN), respectively, in treating small renal tumours in terms of safety, peri-operative morbidity and early oncological outcomes. Between June 2008 and April 2012 56 patients underwent LC and from October 2010 to April 2012, 47 patients underwent RPN using the Da Vinci robotic platform (Intuitive Surgical, Sunnyvale, CA, USA). Data on intra-operative, postoperative and oncological outcomes were collected prospectively, and were analysed and compared for both groups. The median patient ages were 69 and 60 for the LC and RPN groups, respectively (P < 0.05). There was no significant difference in disease stage, but there was a significant difference in tumour size, with patients in the RPN group having larger tumours. The mean operating times were 146 and 159 min for the LC and RPN groups, respectively (P = 0.094) and the mean blood loss was 47 and 94 mL for the LC and the RPN groups, respectively (P = 0.251). The median length of hospital stay (1 day) was the same for both groups and the mean warm ischaemia time was 23 min in the RPN group. The marginal change in preoperative and 6-week postoperative renal function was recorded: the mean postoperative increase in serum creatinine was 5.4 mmol/L in the LC group and 9.2 mmol/L in the RPN group. Of the 47 patients in the RPN group, two (4.3%) were converted to laparoscopic radical nephrectomy because of difficulty in controlling bleeding during hilar dissection. Only two patients (3.6%) had recurrence in the LC group, both of whom were treated with re-cryoablation. A total of 5.4% of patients in the LC and 4.3% in the RPN group had Clavien grade I postoperative complications, one patient in the LC group had a Clavien grade II complication, while 1.8 and 4.3% of patients had Clavien IIIb in the LC and RPN groups, respectively. Our data confirm that LC is a successful, minimally invasive and safe treatment option for the management of small renal tumours, but the apparently similar characteristics of RPN suggest that an increasing proportion of patients, whatever their age or medical comorbidities, may be reasonably offered a robot-assisted extirpative procedure with the likely benefit of lower risk of local recurrence and need for retreatment.