Approach for Renal Tumors With Low Nephrometry Score Through Unclamped Sutureless Laparoscopic Enucleation Technique: Functional and Oncologic Outcomes

Case report: A hybrid technique for a safe nephrectomy in a giant kidney angiomyolipoma

Background

Giant angiomyolipoma is usually associated with genetic syndromes and complications (spontaneous rupture and bleeding, hematuria, hypertension) and mass-related symptoms (flank and abdominal pain).

Case presentation

We present a case of a 20-year-old woman suffering from tuberous sclerosis who was referred to our hospital with a giant angiomyolipoma causing abdominal pain. A contrast-enhanced computed tomography showed a left angiomyolipoma, measuring 28 cm × 17 cm × 27 cm. After a multidisciplinary team discussion, the patient was submitted for a nephrectomy. Percutaneous temporary occlusion of the main renal artery was achieved through an endovascular balloon catheter. Through the balloon catheter guidewire, 2,500 IU of heparin was infused to reduce the risk of tumor vein thrombosis and venous embolism. This allowed a safe kidney manipulation through a left thoracoabdominal approach. The postoperative course was uneventful. Pathology showed a 40 cm × 30 cm × 9 cm and 10 kg AML. One year after surgery, the patient is on follow-up, and her estimated glomerular filtration is 120.5 ml/min/1.73 m².

Conclusion

The present case showed that the endovascular control of the main renal artery could be considered a useful approach to safely managing huge renal masses when renal hilar control is expected to be very difficult.

Intraoperative indocyanine green fluorescence navigation in a robot-assisted partial nephrectomy for a large renal cell carcinoma in a horseshoe kidney

A man in his 60s was referred to the urology department with an incidental finding of large 75 mm mass within a horseshoe kidney. CT imaging highlighted the well-known aberrant arterial anatomy seen in horseshoe kidney which often causes significant surgical challenges.

After careful preoperative planning, the mass was resected successfully during a robot-assisted partial nephrectomy. Intraoperatively, indocyanine green fluorescence navigation helped to confirm arteries supplying area of resection were appropriately clamped, allowing for safe resection of the mass. Histology revealed a chromophobe renal cell carcinoma with clear margins. The patient was discharged on day 4 postoperatively and continues to be cancer free on routine surveillance imaging.

Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary?

Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.

Comparison of Tumor Enucleation and Standard Partial Nephrectomy According to Trifecta Outcomes: A Multicenter Study by the Turkish Academy of Urology, Uro-Oncology Working Group

INTRODUCTION

We aimed to evaluate the impact of the resection technique (tumor enucleation (TE) or standard partial nephrectomy (SPN)) on trifecta outcomes in patients having undergone partial nephrectomy (PN).

MATERIALS AND METHODS

We retrospectively analyzed the clinical and pathologic parameters in patients with localized renal cell carcinoma (pT1-2N0M0) who had undergone PN between January 2001-December 2018 at one of 15 different tertiary referral centers. Multivariable logistic regression analysis was applied to investigate independent predictors of trifecta failure, decreased postoperative renal functions (decreased estimated glomerular filtration rate (eGFR) > 10%), perioperative complications (Clavien-Dindo > 1), and positive surgical margins.

RESULTS

A total of 1070 patients with a mean age 56.11 ± 11.88 years were included in our study. PN was performed with TE in 848 (79.25%) and SPN in 222 (20.75%) patients. Trifecta failure rate was 56.2% for TE and 64.4% for SPN (p = 0.028). On multivariable analysis, TE was associated with less trifecta failure (p = 0.025) and eGFR decrease >10% rates (p = 0.024). On the other hand, there was no statistically significant difference between TE and SPN according to positive surgical margins (p = 0.450) and complication > Clavien-Dindo grade 1 (p = 0.888) rates. The only independent predictive factor for complications > Clavien-Dindo 1 was the Charlson comorbidity index (CCI) (p = 0.001).

CONCLUSION

TE is associated with less trifecta failure than SPN. This result is mainly due to better preservation of renal function with TE.

Concomitant robot-assisted laparoscopic surgeries for upper and lower urinary tract malignancies: a comprehensive literature review

Worldwide, we have witnessed an expansion of robot-assisted laparoscopic surgery (RALS) and thanks to the global adoption of high-resolution diagnostic imaging technologies, an increased incidence of newly diagnosed prostatic, renal and bladder cancers has been recorded with concurrent second primary urological cancer diagnoses increasing by 1.5%. Diverse authors have reported their findings concerning synchronous multi-visceral malignances robotic treatment within the scientific literature. The aim of this study is to comprehensively review all reported articles describing concurrent upper and lower RALS using a singular robotic port scheme within the same intervention for renal malignances and concomitant prostatic or bladder cancers. To the best of our knowledge and vigorous literature search, this is the first study that comprehensively evaluates and reports all combined upper and lower urinary tract surgeries published so far. In carefully selected patients, thanks to multidisciplinary preoperative assessment and surgical planning a combined robotic approach can reduce the morbidity, complications, hospital admissions and the overall length of hospitalization.

The relationships of acute kidney injury duration and severity with long-term functional deterioration following partial nephrectomy

PURPOSE

To evaluate the effect of acute kidney injury (AKI) duration and severity on long-term renal functional outcomes in patients undergoing partial nephrectomy (PN).

METHODS

Altogether 292 consecutive patients undergoing laparoscopic PN from 2010 to 2018 were identified in two medical centers. In addition, the AKI duration {transient AK [≤ 3d] or persistent AKI [> 3d]} was combined with AKI severity (stages) to elucidate their relationships with long-term functional results. Kaplan-Meier (KM) analysis was also used to compare among patients with no AKI, transient AKI, and persistent AKI. Moreover, the Cox-proportional hazards regression model was utilized to assess the risk factors for renal function deterioration.

RESULTS

Altogether 67 patients (22.9%) experienced postoperative AKI. 75% eGFR preserve rate during the follow-up was compared among patients with no AKI, transient AKI and persistent AKI using KM analysis and log-rank test, which revealed significant difference. After adjusting for age and warm ischemia time by multivariate model proportional hazards analysis, AKI duration and severity were identified as the risk factors (Stage 1-transient AKI vs. non-AKI: adjusted hazard ratio (HR) 4.361, 95% confidential interval (CI) [2.062-9.233], p < 0.001; stage 1-persistent AKI vs. non-AKI: adjusted HR 6.706, 95% CI [2.405-18.699], p < 0.001; stage 2/3-transient AKI vs. non-AKI: adjusted HR 8.949, 95% CI [1.571-50.963], p = 0.014; stage 2/3-persistent AKI vs. non-AKI: adjusted HR 13.453, 95% CI [11.353-133.798], p = 0.027).

CONCLUSIONS

The AKI duration after PN is an important risk factor for long-term renal functional deterioration. Besides, AKI duration combined with AKI severity can be more comprehensive to understand the role of AKI on ultimately renal function.

TRIAL REGISTRATION

Chinese ClinicalTrials: ChiCTR2000034080.

Comparison of Sutureless Versus Suture Partial Nephrectomy for Clinical T1 Renal Cell Carcinoma: A Meta-Analysis of Retrospective Studies

Background

Partial nephrectomy (PN) is the recommended treatment for T1 renal cell carcinoma (RCC). Compared with suture PN, sutureless PN reduces the difficulty and time of operation, but the safety and feasibility have been controversial. This meta-analysis was conducted to compare the function and perioperative outcomes of suture and sutureless PN for T1 RCC.

Methods

Systematic literature review was performed up to April 2021 using multiple databases to identify eligible comparative studies. According to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria, identification and selection of the studies were conducted. Meta-analysis was performed for studies comparing suture to sutureless PN for both T1a and T1b RCC. In addition, subgroup analysis was performed on operation time, warm ischemia time, estimated blood loss, and postoperative complications. Sensitivity analysis was used in analysis with high heterogeneity (operation time and estimated blood loss).

Results

Eight retrospective studies were included with a total of 1,156 patients; of the 1,156 patients, 499 received sutureless PN and 707 received suture PN. The results showed that sutureless PN had shorter operative time (I² = 0%, P < 0.001), warm ischemia time (I² = 97.5%, P < 0.001), and lower clamping rate (I² = 85.8%, P = 0.003), but estimated blood loss (I² = 76.6%, P = 0.064) had no difference. In the comparison of perioperative outcomes, there was no significant difference in postoperative complications (I² = 0%, P = 0.999), positive surgical margins (I² = 0%, P = 0.356), postoperative estimated glomerular filtration rat (eGFR) (I² = 0%, P = 0.656), and tumor recurrence (I² = 0%, P = 0.531).

Conclusions

In T1a RCC with low RENAL score, sutureless PN is a feasible choice, whereas it should not be overestimated in T1b RCC.

Single-Site Sutureless Partial Nephrectomy for Small Exophytic Renal Tumors

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.

Functional and oncological outcomes of 3D clampless sutureless laparoscopic partial nephrectomy for renal tumors with low nephrometry score

BACKGROUND

Renal cell carcinoma still represents 2-3% of all tumors but its mortality is decreased in the last decades due to the early detection of small masses and to the innovative surgical techniques. The aim of our study was to evaluate safety and feasibility of clampless and sutureless laparoscopic partial nephrectomy (CSLPN) in terms of intra- and postoperative functional results, complication rate and oncological outcome.

METHODS

We evaluated patients undergoing CSLPN between July 2013 and December 2019. Inclusion criteria were single, organ confined tumor with size ≤4 cm, intraparenchymal depth ≤1.5 cm, renal nephrometry score between 4 and 6 and no close contact with the collecting system.

RESULTS

Overall, 62 patients underwent CSLPN. Mean operative time was 105 minutes, mean intraoperative blood loss was 165 mL. Mean drain time and hospital stay were respectively 2.5 and 4.2 days. Mean 24 hours hemoglobin (Hb) decrease was 2.5 g/dL. No significative variations are described in pre- and postoperative renal function. Twelve patients had postoperative complications. At a median follow-up of 38.5 months all the patients are alive and disease free.

CONCLUSIONS

Different techniques have been proposed to reduce warm ischemia time (WIT). In our experience we found many benefits in an off-clamp procedure: it gives an ischemia-related advantage, reduces the overall operating time, eliminates the risks associated with the isolation of hilar vessels. In conclusion CSLPN is a safe and effective procedure for selected renal masses; it does not increase complication rate and offers excellent functional and oncological outcomes.

Canadian Update on Surgical Procedures (CUSP) Urology Group consensus for intraoperative hemostasis during minimally invasive partial nephrectomy

INTRODUCTION

Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes.

METHODS

A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship-and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting.

RESULTS

An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles).

CONCLUSIONS

Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.

A Propensity Score-Matched Comparison Between Sutureless and Suture Techniques in Laparoscopic Nephron-Sparing Surgery: A Retrospective Non-Randomized Observational Study

Objective: To compare the surgical feasibility, oncological and functional results between sutureless and suture techniques in retroperitoneal laparoscopic nephron-sparing surgery (LNSS). Materials and Methods: This retrospective study collected consecutive patients with a renal mass who underwent retroperitoneal LNSS in two high-volume centers. Propensity score matching (PSM) analysis was conducted to select two baseline homogeneous cohorts. Descriptive statistics was performed both before and after PSM. Moreover, univariate and multivariate logistic analyses were carried out to identify the risk factors of postoperative acute kidney injury (AKI), whereas Kaplan-Meier analysis for functional deterioration (new-onset stage 3 chronic kidney disease [CKD], estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m², or CKD upstaging after surgery) was utilized to compare the two cohorts. Results: After PSM at a ratio of 1:3, the sutureless group (n = 65) was compared with the suture group (n = 152) with no remaining statistically significant differences in baseline characteristics. With regard to patient outcomes, differences in warm ischemia time (WIT) (P < .001), estimated blood loss (P < .001), AKI (P = .002), length of hospital stay (P = .020), and eGFR at discharge (P < .001) were statistically significant. Meanwhile, the postoperative complication rates (9.2% versus 13.8%, P = .378) and positive surgical margins (0% versus 2.0%, P = .556) were not statistically different. At the last follow-up, the eGFR decline percent was the same (-1.5% versus -2.2%, P = .192). No difference was detected on Kaplan-Meier analysis for functional deterioration (log-rank test, P = .304). Conclusions: Sutureless technique in LNSS is safe and feasible, compared with the traditional suture method, with shorter WIT, lower AKI rate, and comparable long-term oncological and functional outcomes.

A preoperative nomogram predicting the pseudocapsule status in localized renal cell carcinoma

Background

Tumor enucleation (TE) surgery for localized renal cell carcinoma (RCC) relies on a complete peritumoral pseudocapsule (PC). Study objective was to develop a preoperative model to predict PC status.

Methods

The prediction model was developed in a cohort that consisted of 170 patients with localized RCC, and data was gathered from 2010 to 2015. Multivariable logistic regression analysis and R were used to generate this prediction model. The statistical performance was assessed with respect to the calibration, discrimination, and clinical usefulness.

Results

The prediction model incorporated the systemic inflammatory markers [neutrophil-lymphocyte ratio (NLR); albumin-globulin ratio (AGR)], CT imaging features (tumor size and necrosis), and clinical risk factors (BMI). The model showed good discrimination, with a C-index of 0.85 (0.78–0.91), and good calibration (P=0.60). The sensitivity and specificity were 62% and 94% respectively. Decision curves and clinical impact curve demonstrated that the current model was clinically useful.

Conclusions

We constructed a model that incorporated both the systematic inflammatory markers and clinical risk factors. It can be conveniently used to preoperatively predict the individualized risk of PC invasion and identify the best candidates to receive TE surgery.

Vessel and Tension-Free Reconstruction During Robot-Assisted Partial Nephrectomy for Hilar Tumors: "Garland" Technique and Midterm Outcomes

Purpose: Robot-assisted partial nephrectomy (RAPN) is increasingly applied to renal hilar tumors. The present study aims to introduce our vessel and tension-free reconstruction technique and discuss the perioperative, functional, and midterm oncologic outcomes of RAPN for hilar tumors in a large cohort. Materials and Methods: We retrospectively reviewed clinical data of 286 consecutive patients with hilar tumors who underwent RAPN from June 2013 to December 2016 in our center. Our anatomy-based "Garland" technique specialized in protecting the large hilar vessels and minimizing the tension of suturing the defect via trans/retroperitoneal approaches for anterior/posterior lip hilar tumors, respectively. Results: "Garland" technique was effectively applied in 286 patients, and the warm ischemia time was 18.2 ± 4.1 minutes. Median estimated blood loss for RAPN was 100 mL (interquartile range [IQR]: 50-200 mL). Median operative time was 120 minutes (IQR: 90-150 minutes). No patient was converted to open surgery. Postoperative stay was 4.0 days (IQR: 4.0-5.0 days). Three patients (1.1%) had positive surgical margin. Two patients (0.7%) received blood transfusion. Complications occurred in 20 patients (7.0%), in which 18 patients were Clavien 1 and 2. Three patients (1.1%) had local recurrence. All patients were alive at a 48-month median follow-up (range: 24-66 months). Conclusions: "Garland" technique is safe and feasible for hilar tumor resection and kidney reconstruction. The trans/retroperitoneal approaches are options for anterior/posterior hilar tumors. Longer follow-up involving more patients is required.