Has Sliding-Clip Renorrhaphy Eliminated the Need for Collecting System Repair During Robot-Assisted Partial Nephrectomy?

Robotic partial nephrectomy: Indications, patient selection, and setup for success

Robot-assisted partial nephrectomy (RAPN) has readily become the benchmark treatment of small renal masses (SRMs). The management of SRMs is focused on preserving renal function and limiting the morbidity of a traditional open operation, thus greatly impacting overall prognosis and long-term survival. Indications and techniques have evolved over the last 2 decades. In this article, we discuss the application of this nephron-sparing technique regarding its indications, surgical considerations, and functional outcomes.

Comparison of surgical outcomes of robot-assisted laparoscopic partial nephrectomy performed by a single experienced surgeon according to two reconstruction methods, including single-layer and double-layer renorrhaphy

This study aimed to assess the surgical outcomes of single-layer versus double-layer renorrhaphy in robot-assisted laparoscopic partial nephrectomy (RAPN) performed by an experienced surgeon.We enrolled 655 patients who underwent RAPN between January 2019 and June 2023. After excluding those with multiple tumors or incomplete medical records, 554 patients were included in the final analysis. We compared surgical outcomes between single-layer renorrhaphy (outer cortical closure) and double-layer renorrhaphy (inner layer suture and outer cortical closure), adjusting for preoperative factors such as sex, age, body mass index, American Society of Anesthesiologists score, preoperative estimated glomerular filtration rate (eGFR), preoperative complications (diabetes or hypertension), surgical approach (transperitoneal or retroperitoneal), tumor size, and tumor complexity, using propensity score matching. Of the 554 patients analyzed, 59 were classified into the single-layer group and 495 into the double-layer group. Before matching, the double-layer group had more complex and larger tumors. After matching, 58 patients were included in each group. The single-layer group showed significantly shorter operative times (91 min vs. 100 min, p = 0.0361), lower estimated blood loss (EBL) (7.9 ml vs. 27 ml, p = 0.021), and better preservation of eGFR (- 1.2% vs. - 5.1%, p = 0.0313). Other outcomes, such as perioperative complications and postoperative hospital stay, were not significantly different between the groups. Single-layer renorrhaphy demonstrated better surgical outcomes, including shorter operative time, lower EBL, and better preservation of kidney function, compared to double-layer renorrhaphy. These findings suggest that single-layer reconstruction may optimize RAPN outcomes in selected patients.

Impact of Inner Layer Renorrhaphy Suture on Renal Artery Pseudoaneurysm Formation Following Robotic-assisted Partial Nephrectomy

OBJECTIVE

To report the impact of resection base inner layer renorrhaphy suture type on renal artery pseudoaneurysm (RAP) rate following robotic-assisted partial nephrectomy (RAPN).

METHODS

Five hundred and sixty-three consecutive RAPNs performed by a single surgeon were retrospectively reviewed. Patients were classified into 3 categories: (1) No base suture, (2) monofilament barbed suture (2-0 V-Loc 180 absorbable suture, Medtronic, Minneapolis, MN), (3) polyglactin 910 (2-0 Vicryl coated suture, Ethicon Inc, Cincinnati, OH). In a secondary analysis, we evaluated suturing (Vicryl and V-Loc) vs no base suture. All patients had outer cortical renorrhaphy performed with 0-Vicryl suture utilizing the standard sliding clip technique.

RESULTS

One hundred ten patients (19.5%) had V-Loc suturing, 255 patients (45.3%) had Vicryl suturing, and 198 patients (35.2%) had no base suture. Patients had a median age of 62.8years (interquartile range: 53.5-69.7) and median RENAL score was 8 (6-9). Median mass size from preoperative imaging was 3.0 cm (2.5-4.0) for V-Loc, 3.3 cm (2.5-4.2) for Vicryl, and 2.0 cm (1.8-3.0) for no base suture (P < .001). Overall, 21 patients (3.7%) developed a symptomatic postoperative RAP. The rate of RAP was 3.6% (4/110) for V-Loc, 3.9% (10/255) for 2-0 Vicryl, and 3.5% (7/198) for no base suture (P = 1.00). Similarly, the rate of RAP was 3.5% (7/198) for no base suture and 3.8% (14/365) for base suture (P = 1.00).

CONCLUSION

Utilization of base suture and type of base suture used during RAPN was not predictive of postoperative RAP development.

Renorrhaphy techniques in minimally invasive partial nephrectomy: a systematic review of the literature

INTRODUCTION

In the absence of consensus on the optimal approach to renorrhaphy in partial nephrectomy, this systematic review aims to assess the various renorrhaphy techniques and their impact on surgical outcomes.

EVIDENCE ACQUISITION

A systematic review of the literature was performed in March 2022, using PubMed and Scopus, without time restrictions and research filters for studies investigating renorrhaphy techniques in partial nephrectomy. Studies providing sufficient details on renorrhaphy techniques and their outcomes during minimally invasive partial nephrectomy (PN) were included in this analysis.

EVIDENCE SYNTHESIS

Thirty-one studies with 5720 patients were included in the analysis. In most studies, tumor diameter was <4 cm. RENAL and PADUA scores as well as tumor locations were heterogeneous between the studies. The results of the use of hemostatic agents were conflicting among different studies with limited evidence regarding the benefits of its routine use in partial nephrectomy. The use of barbed and running sutures was associated with a reduced warm ischemia time. While some studies showed a decreased warm ischemia time when omitting cortical renorrhaphy, others found that it may lead to higher incidence of minor complications without any significant improvement in other outcomes.

CONCLUSIONS

There is ongoing research to determine the optimal approach to renorrhaphy. The current evidence on the routine use of hemostatic agents is limited. The use of certain techniques such as barbed sutures, sliding clips and running sutures reduced the warm ischemia time. The omission of cortical renorrhaphy is still controversial.

Comparison of robot-assisted partial nephrectomy with soft coagulation and double-layer technique for complex and non-complex tumors

OBJECTIVES

To compare the postoperative outcomes of robot-assisted partial nephrectomy when only the inner layer is sutured (single-layer technique with soft coagulation) with those when sutures are placed in the inner and outer layers (double-layer technique) in patients with and without complex renal tumors.

METHODS

This retrospective three-institution study included 371 patients with renal tumors who underwent robot-assisted partial nephrectomy with a double-layer technique or a single-layer technique with soft coagulation. Tumors that were cT1b, completely embedded, located in the renal portal, or had a RENAL score of ≥10 were considered complex. Relevant data were collected from hospital records. Propensity score matching was performed to minimize selection bias.

RESULTS

Propensity score matching created 83 patient pairs with non-complex tumors and 32 with complex tumors. Regardless of tumor complexity, there was no significant difference in operation time, console time, warm ischemia time, positive surgical margin rate, or length of hospital stay between the double-layer and single-layer groups. Although Clavien-Dindo grade I-II urinomas not requiring intervention were significantly more common in the single-layer group regardless of tumor complexity, there was no significant between-group difference in the rate of decline in renal function or grade III-IV complications.

CONCLUSION

Single-layer suturing with soft coagulation achieves renal function and perioperative outcomes comparable to those of double-layer suturing regardless of complexity.

Robotic-assisted partial nephrectomy: single-layer cortical renorrhaphy is associated with reduced rate of renal artery pseudoaneurysm compared to double-layer renorrhaphy

The study compares the outcome of patients who underwent single-layer outer cortical renorraphy (SLOCR) and double-layer cortical renorraphy (DLR) in our institution. The retrospective analysis of 181 patients who underwent RAPN was performed. Propensity score matching was accomplished on 67 patients using age, BMI, size, distance from collecting system, hilar location and pathological stage. Intraoperative factors assessed included warm ischemia time, renorraphy time, blood loss and operative duration (Levey et al. in Clin Chem 53:766-772, 2007) Post-operative hospital stay, complications like renal artery pseudoaneurysm (RAP), hemorrhage, urine leak and reduction in eGFR were measured. The 67 patients in SLOCR group were compared with similar number in the DLR group using propensity score matching. Warm ischemia time (P < .001), renorraphy time (P < .001) and symptomatic pseudoaneurysm (RAP) rate (P < .001) were significantly less in SLOCR group. SLOCR is associated with reduced rate of symptomatic post-operative RAP.

Robotic Partial Nephrectomy: Update on Techniques

Surgical techniques for robot-assisted partial nephrectomy are driven by the aims of simplifying the most challenging surgical steps, maximizing functional and oncologic outcomes, and consistently pushing the envelope on possibilities. Over the past several years, we have seen an emergence in not only innovation in surgical technique, and robotic platforms, but integration of a variety of imaging techniques. We believe with developing robotic expertise, practicing urologists will continue to push the envelope in nephron preservation and complication-free recovery.

Omitting Cortical Renorrhaphy in Robot-Assisted Partial Nephrectomy: Is it Safe? A Single Center Large Case Series

Introduction: Preserving renal function after robot-assisted partial nephrectomy (RAPN) is important and influenced by the technique of renal reconstruction among other parameters, including ischemia time and amount of healthy renal tissue resected. It is believed that reconstruction with a second layer of cortical renorrhaphy is necessary to prevent urinary leaks and postoperative bleeding, but this is associated with the potential loss of healthy renal parenchyma and may result in worse outcomes postoperatively. Purpose: To assess the safety of omitting cortical renorrhaphy during RAPN. Patients and Methods: A retrospective analysis of 146 consecutive patients undergoing a RAPN with single or double layer renorrhaphy at the Wirral University Teaching Hospital from 2014 to 2019. Data obtained included: Patient demographics, tumor RENAL nephrometry, Perioperative parameters; blood loss, duration, and warm ischemia time (WIT), Postop complications, change in estimated glomerular filtration rate (eGFR) (pre and 3 months postop), length of stay, and oncologic outcomes. Results: In total 146 patients were identified. One hundred-six had double renorrhaphy and 40 inner layer only renorrhaphy. No significant differences were seen between these two cohorts in terms of patient demographics, RENAL nephrometry score, tumor size, or location. Perioperative parameters showed a reduced duration of surgery in the single renorrhaphy group with a mean of 125 minutes compared to143 minutes in the double renorrhaphy (p = 0.006) and a tendency toward a shorter WIT of 12.9 minutes vs 14.0 minutes reaching borderline statistical significance (p = 0.05) but no difference in blood loss volume (p = 0.25). Postoperatively there was no statistical difference in the length of hospital stay (p = 0.85), loss in eGFR at 3 months (0.06), or complication (p = 0.56). After a median follow-up of 35 months no recurrences or deaths were observed in either group. Conclusions: Omission of cortical renorrhaphy appears feasible and safe with no urine leaks or excess complications observed.

Renorrhaphy techniques and effect on renal function with robotic partial nephrectomy

PURPOSE

The role of robotic partial nephrectomy (RPN) is becoming increasingly prevalent in managing small renal masses. Renal functional outcomes have been reported with relation to the amount of healthy renal parenchyma resected and ischemia time; however, there is limited data on the effect of renorrhaphy on long-term renal function. Our aim is to evaluate the impact of renorrhaphy technique on renal functional outcomes.

METHODS

A nonsystematic literature review was performed to retrieve articles assessing renorrhaphy techniques and renal function outcomes, specifically focusing on single-layer vs. traditional two-layer renorrhaphy.

RESULTS

Performing single-layer renorrhaphy while omitting cortical renorrhaphy appears to improve renal function postoperatively, based on very limited studies in the literature that were evaluated.

CONCLUSION

Single-layer renorrhaphy may be associated with improved postoperative renal function and could prove to be useful in patients with chronic renal insufficiency or solitary kidney. The ongoing clinical trial NCT02131376 may provide further information on the impact of renorrhaphy technique on long-term renal function.

Elimination of surgical drains following robotic-assisted partial nephrectomy

To prospectively evaluate outcomes of robotic-assisted partial nephrectomy (RAPN) following elimination of surgical drains. 100 consecutive drainless RAPN performed by a single surgeon were analyzed following a previously published quantitative assessment of drain creatinine/serum creatinine ratios. This cohort was compared to 100 preceding RAPN with drains. Variables analyzed included pre-operative patient/tumor characteristics and post-operative outcomes including post-operative estimated glomerular filtration rate (eGFR), length of hospital stay (LOS), and complications. There was no significant difference in median patient age, sex, body mass index, ASA score, or pre-operative eGFR between the two groups. The preceding 100 patients with drains did have larger median renal size (3.5 vs 2.6 cm, p < 0.001), higher median RENAL scores (9 vs 8, p < 0.001), and longer warm ischemia time (21 vs 18 min, p = 0.004). Patients without drains had shorter median LOS (2.0 days vs 3.0 days, p < 0.001), fewer Grade III or higher post-operative complications (4% vs 10%, p = 0.007), and no difference in 1 month percent change in eGFR (- 13% vs - 11%, p = 0.84). After adjusting for confounding variables there was no difference in LOS (OR 1.50, p = 0.31), Grade III-V complications (OR 1.49, p = 0.63), or 1 month percent change in eGFR (OR 2.3, p = 0.41) between the two groups. One patient in the drainless group required a post-operative drain for a urine leak diagnosed 10 days following RAPN. Omission of drains is safe in RAPN and does not appear to offer a clinical advantage.

The incidence and pattern of renal cell carcinoma recurrence after robotic partial nephrectomy

Background

Robotic partial nephrectomy (RPN) is a rapidly growing treatment for small renal mass (SRM). In fact, RPN has shown good functional and oncologic outcome. In this manuscript, we are reporting on the incidence and pattern of recurrence of renal cell carcinoma (RCC) treated with RPN.

Patients and Methods

We reviewed prospectively collected data of patients who underwent RPN between September 2009 and March 2018. We selected patients with final pathologic diagnosis of RCC after the resection of their SRM. We described the incidence and pattern of recurrence in the patients who had it.

Results

A total of 335 patients with SRM underwent RPN. We found 269 patients to have RCC on the final pathologic evaluation of the SRM. Eight cases of recurrence were found with a recurrence rate of 2.9% after the mean follow-up period of 31 months (range 18-72). The pattern of recurrence presented as follows: two patients (0.7%) had trocar site recurrence (TSR), one patient (0.37%) had locoregional recurrence, and three patients (1.1%) had recurrence of the disease at the resection bed. Two patients (0.7%) developed second primary tumor in the other kidney. No cancer-related mortality occurred during the follow-up period.

Conclusion

TSR, locoregional recurrence, tumor bed recurrence, and contralateral tumor development are observed patterns of RCC recurrence after RPN. Recurrence was seen in up to 72 months. RPN provides great cancer control and high cure rate when utilized to treat RCC presenting as SRM.

Systematic Review and Pooled Analysis of the Impact of Renorrhaphy Techniques on Renal Functional Outcome After Partial Nephrectomy

Despite the important relationship between renorrhaphy and functional outcomes of partial nephrectomy, the urological guidelines do not provide recommendations about the optimal renorrhaphy technique. We carried out the first pooled literature analysis of the impact of suture technique on ultimate renal function after partial nephrectomy. Three studies comparing interrupted versus running suture including data on glomerular filtration rate (GFR) were included, for a total of 124 versus 269 patients. No significant differences were found between pre- and postoperative GFR in either patients who received an interrupted suture (weighted mean difference, -4.88ml/min, 95% confidence interval [CI] -11.38; 1.63, p=0.14) or those who received a running suture (-3.42ml/min, 95% CI -9.96; 3.12, p=0.31). Three studies comparing single- versus double-layer renorrhaphy included data on GFR (321 vs 199 patients). A benefit in functional outcomes favored single-layer technique (-3.19ml/min, 95% CI -8.09; 1.70, p=0.2 vs -6.07ml/min, 95% CI -10.75; -1.39, p=0.01). In conclusion, our quantitative synthesis suggests a renal functional benefit of the single-layer closure during partial nephrectomy. PATIENT SUMMARY: The available studies on renal functional data included in the present review suggest that "less is more" for renorrhaphy after partial nephrectomy. The single-layer renorrhaphy technique showed advantages in renal functional outcomes compared with the double-layer technique.

Suture techniques during laparoscopic and robot-assisted partial nephrectomy: a systematic review and quantitative synthesis of peri-operative outcomes

OBJECTIVE

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri-operative outcomes after minimally invasive partial nephrectomy (MIPN).

MATERIALS AND METHODS

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot-assisted partial nephrectomy and comparative studies focused on peri-operative outcomes were included in qualitative and quantitative analyses, respectively.

RESULTS

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon's experience, robot-assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non-barbed suture. The single-layer suture technique was associated with shorter operating and ischaemia time than the double-layer technique. No comparisons were possible concerning renal functional outcomes because of non-homogeneous data reporting.

CONCLUSIONS

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double-layer suture.