Surgical details and renal function change after robot‐assisted partial nephrectomy

Impact of Robotic-Assisted Partial Nephrectomy with Single Layer versus Double Layer Renorrhaphy on Postoperative Renal Function

We aimed to investigate the differences in renal function between patients who underwent single inner-layer renorrhaphy (SILR) or double-layer renorrhaphy (DLR) among those with renal tumors who underwent robot-assisted partial nephrectomy (RAPN). This retrospective multicenter cohort study was conducted between November 2018 and October 2023 at two institutions and included patients who underwent RAPN. In total, 93 eligible patients who underwent RAPN were analyzed. Preoperative renal function and prevalence of chronic kidney disease were not significantly different between the two groups. Although urinary leakage was observed in three patients (5.9%) in the SILR group, there was no significant difference between the two groups regarding surgical outcomes (p = 0.249). Serum creatinine levels after RAPN were significantly lower in the SILR group than in the DLR group on postoperative days 1 and 365 following RAPN (p = 0.04). The estimated glomerular filtration rate (eGFR) was significantly lower in the DLR group than in the SILR group only on postoperative day 1; however, there was no significant difference between the two groups thereafter. Multivariate analysis showed that the method of renorrhaphy was not a predictor for maintaining renal function after RAPN even though it was associated with eGFR on postoperative day 1.

Retroperitoneoscopic Clampless, Sutureless Hybrid Therapy in the Management of Renal Hilar Tumors

OBJECTIVE

We aimed to investigate the outcomes and feasibility of a retroperitoneoscopic clampless, sutureless hybrid technique in the management of renal hilar tumors.

METHODS

A retrospective cohort of consecutive patients with renal hilar tumors who received retroperitoneoscopic clampless, sutureless hybrid therapy between January 2017 and April 2021 was included. The hybrid surgical technique involved microwave ablation (MWA), followed by clampless tumor enucleation and sutureless hemostasis. Surgical, pathological, and oncological outcomes were recorded and analyzed.

RESULTS

Sixty patients were included in this study. The median tumor size was 3.5 cm (2-5), the median RENAL score was 7 (range 6-10), the median operative time was 110 min (70-130), and the median estimated blood loss was 80 mL (30-130). The median length of postoperative hospital stay was 3 days (2-4), and no warm ischemia time was observed, except in one patient who required conversion to conventional on-clamp laparoscopic partial nephrectomy (LPN) with a 10 min warm ischemia time. Three minor complications (Clavien-Dindo grade I) and one major complication (Clavien-Dindo grade III) were recorded postoperatively. Thus far, no blood transfusions have been required. Renal dysfunction or tumor recurrence did not occur within a median follow-up of 45 months.

CONCLUSION

The retroperitoneoscopic hybrid technique involving MWA, clampless tumor enucleation, and sutureless hemostasis is a feasible and safe option for the management of selective renal hilar tumors. Complete tumor removal with maximal renal function preservation can be achieved, with a low complication rate.

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 surgical outcomes and split renal function between laparoscopic and robot-assisted partial nephrectomy: a propensity score-matched analysis

PURPOSE

The objective of this study was to compare perioperative outcomes and total and split renal function between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN). Predictive risk factors of preservation of operated renal function were also assessed.

METHODS

We retrospectively analyzed 173 patients who underwent LPN (n = 84) or RAPN (n = 89) between 2010 and 2020. After propensity score matching (1:1), perioperative outcomes and total and split renal function were assessed. Logistic regression analysis was used to evaluate predictive risk factors of preservation of operated renal function. Trifecta criteria were defined as negative surgical margins, warm ischemia time (WIT) < 25 min, and no complications more than Clavien-Dindo grade II within 4 weeks after surgery. Split renal function was evaluated by mercaptoacetyltriglycine renal scan.

RESULTS

After propensity score matching, 42 patients were allocated to each group. RAPN was associated with significantly shorter WIT (RAPN vs LPN: 12 vs 22 min; p < 0.0001) and higher trifecta achievement rate (93.3 vs 64.2%; p < 0.0001). Other perioperative outcomes and total and split renal function were not significantly different between LPN and RAPN. The R.E.N.A.L. nephrometry score (RNS) was a predictive risk factor of preservation of operated renal function in the multivariable logistic regression analysis (odds ratio 1.68, 95% confidence interval 1.29-2.20, p < 0.0001).

CONCLUSIONS

RAPN improved WIT and trifecta achievement rate, but it did not improve the preservation of operated renal function, for which RNS was found to be a strong predictive risk factor.

Initial experience of robot-assisted radical nephrectomy in Japan: Single institutional study of 12 cases

INTRODUCTION

To evaluate the initial experience of robot-assisted radical nephrectomy (RARN) in a single institution in Japan.

METHODS

This study included a total of 12 patients with renal tumors who were not preoperatively regarded as optimal candidates for robot-assisted partial nephrectomy (RAPN) and subsequently treated with RARN between April 2019 and June 2021 at our institution. Comprehensive perioperative outcomes in these patients were retrospectively analyzed.

RESULTS

Of the 12 included patients, 10 and two were male and female, respectively, and the median age was 66 years. The median tumor diameter was 44 mm, and four, four and four patients were classified into cT1a, cT1b and cT3a, respectively. There was no patient requiring open conversion, and the median operative and console times were 167 and 79 minutes, respectively. The median estimated blood loss was 42 cc, and no patient required blood transfusion. During the perioperative period, no major complication corresponding to Clavien-Dindo grade ≥3 occurred. Nine, two and one patient were pathologically diagnosed with clear cell carcinoma (CCC), non-CCC and benign cyst, respectively, and there was no patient who developed recurrent diseases.

CONCLUSIONS

Considering complicated tumor characteristics not amenable to RAPN in this series, such as an intravenous tumor thrombus or previous history of open partial nephrectomy, perioperative outcomes of initial experience with RARN in Japan could be considered favorable. Collectively, these findings suggest that RARN may be a promising alternative to laparoscopic radical nephrectomy for patients with complicated renal tumors, contraindicated for RAPN.

Outcomes of gasless laparoendoscopic single-port partial nephrectomy in 356 consecutive patients: Feasibility of a clampless and sutureless technique

OBJECTIVES

To investigate the outcomes and feasibilities of gasless laparoendoscopic single-port clampless sutureless partial nephrectomy.

METHODS

We reviewed 356 consecutive patients with primary unilateral non-metastatic renal masses who underwent gasless laparoendoscopic single-port partial nephrectomy (2011-2018), which was performed retroperitoneally using a three-dimensional flexible endoscope, without vascular clamping or renorrhaphy in principle.

RESULTS

The median tumor size was 2.5 cm, and 213 (60%), 105 (29%), and 38 (11%) patients had peripheral, central, and hilar tumors, respectively. Clampless and sutureless partial nephrectomy was accomplished in 337 patients (95%), while eight (2%) and 16 (4%) patients required vascular clamping and renorrhaphy, respectively. The median operative time and blood loss were 220 min and 266 mL, respectively; eight patients (2%) received blood transfusion. Clavien-Dindo grade 3a complications occurred in 27 patients (8%); all these patients had urinary leakage treated with ureteral stent placement, one of whom also developed a postoperative pseudoaneurysm. Among 324 patients diagnosed with renal cell carcinoma, six (2%) had positive surgical margins, and one (0.3%) and seven (2%) developed metastatic and local recurrences, respectively. During a median follow-up of 54 months, no patient died from kidney cancer. The median percent decrease in estimated glomerular filtration rate at 3 months after surgery was 5.7%. No patient experienced postoperative acute renal failure, while one patient with preexisting renal impairment started dialysis at 70 months after surgery.

CONCLUSIONS

Clampless and sutureless partial nephrectomy can be safely accomplished in most patients undergoing gasless laparoendoscopic single-port surgery, yielding favorable oncological and functional outcomes.