Open partial nephrectomy: ancient art or currently available technique?

A novel mini-retractor for retroperitoneal laparoscopic partial nephrectomy

BACKGROUND

Retroperitoneal partial nephrectomy (RLPN) is the premier treatment for localized renal tumors despite narrow operation space. Many efforts have been taken to facilitate the operation of RLPN, but the optimal resolution remains debatable.

OBJECTIVE

To explore the feasibility of using Mini-lap to improve workspace and surgical vision in RLPN.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective review of 51 patients who underwent RLPN with Mini-lap from January 2018 to December 2020 was conducted.

SURGICAL PROCEDURE

Standard RLPN under three poles was performed in all cases. We highlighted the usage of Mini-lap (Teleflex Minilap percutaneous Surgical System) as a novel retractor in RLPN.

OUTCOME AND MEASUREMENTS AND STATICAL ANALYSIS

Demographics, preoperative, intraoperative, and postoperative outcomes were assessed.

RESULTS AND LIMITATIONS

All 51 cases completed RLPN with three ports successfully and no conversion to open surgery. The mean diameter of tumors was (3.53 ± 1.05) cm, in which 62.7% (32/51) were located anteriorly. The operation time and warm ischemic time (WIT) were (86.7 ± 15.9) min and (25.6 ± 5) min respectively. Minor complications (Clavien grade 1-2) occurred in 6 cases. The limitations were small sample size, retrospective design, and absence of control.

CONCLUSIONS

Mini-lap could be used as a mini-retractor in RLPN, sparing extra assistant ports, expanding workspace, and optimizing vision.

PATIENT SUMMARY

With highlights of larger workspace and less instrument interference, mini-lap could be applied in retroperitoneal laparoscopic partial nephrectomy.

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.

Active surveillance for small renal masses in elderly patients does not increase overall mortality rates compared to primary intervention: a propensity score weighted analysis

BACKGROUND

The aim of the study was to test the effect of active surveillance (AS) versus primary intervention (PI) on overall mortality (OM) in elderly patients diagnosed with SRM.

METHODS

Elderly patients (75 years or older) diagnosed with SRMs (<4 cm) and treated with either PI (i.e. partial nephrectomy or kidney ablation) or AS between 2009 and 2018 were abstracted from the renal surgery in the elderly (RESURGE) and Delayed Intervention and Surveillance for small Renal Masses (DISSRM) datasets, respectively. OM rates were estimated among groups with Kaplan Meier method and Cox proportional hazards regression models after applying inverse probability of treatment weighting (IPTW). Multivariable logistic regression model was used to estimate IPTW. Covariates of interest were those unbalanced and/or significantly correlated with the treatment choice or with OM.

RESULTS

A total of 483 patients were included; 121 (25.1%) underwent AS. Sixty patients (12.4%) died. Overall, 6.7% of all deaths were related to cancer. IPTW-Kaplan Meier curves showed a 5-year overall survival rates of 70.0±3.5% and 73.2±4.8% in AS and PI groups, respectively (IPTW-Log-rank P value=0.308). IPTW-Cox regression model did not show meaningfully increased OM rates in AS group (HR: 1.31, 95% CI: 0.69-2.49).

CONCLUSIONS

AS represents an appealing treatment option for very elderly patients presenting with SRM, as it avoids the risks of a PI while not compromising the survival outcomes of these patients.

Is there a clinical role for frozen section analysis during partial nephrectomy? A multicenter experience over 10 years

BACKGROUND

Frozen section analysis (FSA) is frequently performed during partial nephrectomy (PN). We investigate the utility of intraoperative FSA by evaluating its impact on final surgical margin (SM) status.

METHODS

Between January 1995 and December 2005, a series of patients who were treated with open PN for renal cell carcinoma was prospectively analyzed. During PN, each patient underwent a FSA on renal parenchyma distal margin. If FSA was positive for infiltration a deeper excision was performed till obtaining a negative FSA. SM outcome of the FSA was compared with the final pathology report. Recurrence-free survival (RFS) and cost analysis on the FSA performed were analyzed.

RESULTS

A total number of 373 patients were enrolled. FSA was performed in all the patients considered for PN. Fifteen patients had a conversion to radical nephrectomy. Positive SMs at the definitive pathological outcome were found in 36 patients (9.6%). FSA was positive in eight patients (2.1%). In that eight cases after a deeper excision the definitive pathological outcome on SM was still positive in two cases. FSA revealed just 14.3% of the positive SM. Patients with positive SM had a worse follow up considering RFS (P<0.05). Kaplan-Meier analysis revealed that FSA did not considerably contribute to prevent recurrence (P=0.35). 1438 euros was the mean cost of performing a FSA during PN.

CONCLUSIONS

FSA during PN does not reduce the risk of positive SMs. The use of FSA has also a higher cost related to the procedure.

Open versus robotic partial nephrectomy: Systematic review and meta-analysis of contemporary studies

OBJECTIVES

To compare perioperative outcomes of robotic-assisted partial nephrectomy (RaPN) with open partial nephrectomy (OPN).

METHODS

Systematically search through PubMed, Embase, ClinicalKey, Cochrane Library, ProQuest, ScienceDirect, Web of Science, and ClinicalTrials.gov for eligible studies was performed to April 11, 2018. A meta-analysis was conducted for studies comparing RaPN and OPN. Confounding variables were assessed by meta-regression or subgroup analysis.

RESULTS

This study included 34 studies with 60 808 patients. Meta-analysis revealed less blood loss, less transfusion, longer operative time, less postoperative complications, lower readmission rate, shorter length of stay, and less estimated glomerular filtration rate (eGFR) decline in RaPN groups. The superiority of RaPN in blood loss was attenuated with highly complex renal masses. The superiority of RaPN in intraoperative complications was strengthened with renal hilar control. The advantage of RaPN in surgical margin was increased in patient with body mass index (BMI) < 28.

CONCLUSIONS

Compared with OPN, RaPN provided lower morbidities and better renal function preservation.

Open partial nephrectomy when a non-flank approach is required: indications and outcomes

PURPOSE

To evaluate indications/outcomes for open partial nephrectomy (OPN) when non-flank approaches are required, with comparison to patients managed with the flank approach. Outcomes with a non-flank approach are presumed less favorable yet there have been no previous reports on this topic.

METHODS

2747 OPNs were performed (1999-2015) and 76 (2.8%) required a non-flank approach. We also reviewed all traditional flank OPNs performed during odd years in this timeframe yielding 1467 patients for comparison.

RESULTS

Overall, median tumor size was 3.5 cm and 274 patients (18%) had a solitary kidney. Non-flank patients were younger, and tumor size and clinical/pathologic stage were significantly increased for this cohort, but the groups were otherwise comparable. Indications for non-flank OPN included large tumor size/locally advanced disease (n = 21), need for simultaneous surgery (n = 25), previous flank incision or failed thermoablation (n = 13), or congenital/vascular abnormalities (n = 9). The most common non-flank approach was anterior subcostal (n = 39, 51%). Operative times, estimated blood loss, positive margins, and functional decline were all modestly increased for non-flank patients. Intraoperative and genitourinary complications were more common in non-flank patients (p < 0.05), although all were manageable, typically with conservative measures. There were no mortalities among non-flank patients and none required long-term dialysis.

CONCLUSIONS

Our series, the first to address this topic, suggests that outcomes with non-flank OPN are generally less advantageous likely reflecting increased tumor/operative complexity. However, complications in this challenging patient population are manageable and final dispositions are generally favorable. Our findings should be useful for counseling regarding potential outcomes when a non-flank incision is required.

Astragalus polysaccharide, a component of traditional Chinese medicine, inhibits muscle cell atrophy (cachexia) in an in vivo and in vitro rat model of chronic renal failure by activating the ubiquitin-proteasome pathway

The present study aimed to determine the effect of Astragalus polysaccharide (APS) in an in vivo and in vitro rat model of muscle atrophy (cachexia) caused by chronic renal failure (CRF), along with the potential corresponding roles of atroglin-1 and the ubiquitin-proteasome pathway. A rat model of CRF was established using subtotal bilateral nephrectomy. It was observed by reverse transcription-quantitative polymerase chain reaction and western blot analysis that APS and the specific inhibitor of nuclear factor (NF)-κB, pyrrolidine dithiocarbamate (PDTC), significantly reduced the expression of atrogin-1, ubiquitin and the NF-κB subunit p65 mRNA in rat skeletal muscle in vivo and in vitro, respectively (P<0.05). NF-κB and PDTC also markedly reduced the expression of atrogin-1, ubiquitin and p65 protein. In addition, cultured rat myoblasts pretreated with tumor necrosis factor (TNF)-α exhibited significantly reduced expression of atrogin-1, ubiquitin and p65 mRNA in vitro (P<0.05). Fluorescence microscopy was subsequently used to evaluate TNF-α-treated myoblasts administered with APS or PDTC, whereby no evidence of muscle cell atrophy was observed in cells treated with APS. These data suggest that APS may delay muscle cell atrophy associated with cachexia in CRF by targeting atrogin-1 and the ubiquitin-proteasome pathway.

Open partial nephrectomy in renal cell cancer - Essential or obsolete?

Since the first partial nephrectomy was first conducted 131 years ago, the procedure has evolved into the gold standard treatment for small renal masses. Over the past decade, with the introduction of minimally invasive surgery, open partial nephrectomy still retains a valuable role in the treatment of complex tumours in challenging clinical situations (e.g. hereditary renal cancer or single kidneys), and enables surgeons to push the boundaries of nephron-sparing surgery. In this article, we consider the origin of the procedure and how it has evolved over the past century, the surgical techniques involved, and the oncological and functional outcomes.