Comparison of perioperative outcomes with or without renorrhaphy during open partial nephrectomy: A propensity score-matched analysis

Predictors of renal function deterioration at one year after off-clamp non-renorrhaphy partial nephrectomy

BACKGROUND

Preservation of renal function is an important goal in renal cell carcinoma-related surgery. Although several case-dependent techniques for renal pedicle clamping and hemostasis have been used, their effects on long-term renal function are controversial.

METHODS

The clinical records of 114 patients who underwent off-clamp non-renorrhaphy open partial nephrectomy at our hospital were retrospectively reviewed. Perioperative estimated glomerular filtration rate (eGFR) preservation was calculated, and predictors of eGFR decline 12 months post-surgery and overtime deterioration of renal function were identified using a multivariate regression analysis.

RESULTS

The median patient age was 65 years, and the median tumor size was 27 mm. The mean eGFR preservation at 1, 3, and 12 months post-surgery were 90.1%, 89.0%, and 86.9%, respectively. eGFR decline at 1 and 3 months were associated with poor eGFR preservation at 12 months with the odds ratio (95% confidence interval (CI)) of 1.97 and 3.157, respectively. Multivariate regression analyses revealed that tumor size was an independent predictor of eGFR decline at 12 months. Among 65 patients with eGFR preservation over 90% at 1 month post-surgery, eGFR value of 28 patients deteriorated below 90% at 12 months post-surgery compared with preoperative eGFR. Tumor size and eGFR preservation at 1 month were independent predictors of long-term renal function deterioration.

CONCLUSION

Tumor size predicted eGFR decline 12 months post-surgery. Only a mild decline in eGFR was observed between 3 and 12 months after open partial nephrectomy. Tumor size and eGFR preservation at 1 month predicted the deterioration of renal function over time.

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN's surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

Surgical Management of Localized Disease and Small Renal Masses

The incidence of renal cancer has increased over the past several decades, but mortality has declined. This is thought to be related in part to earlier detection of renal masses which portend excellent 5-year survival rates. Management of small renal masses and localized disease include both nonsurgical and surgical options. The choice of intervention is ultimately based on comprehensive evaluation and shared decision-making. This article provides a comprehensive review of the current surgical management options for localized renal cancer.

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.

Natural history of asymptomatic renal artery pseudoaneurysm after robot-assisted partial nephrectomy

Background

We assessed the natural history of renal artery pseudoaneurysm (RAP) after robot-assisted partial nephrectomy (RAPN).

Methods

From May 2016 to September 2020, 106 patients underwent RAPN for renal tumors at our institution. Among 100 patients, excluding 6 who were ineligible for contrast-enhanced computed tomography (CE-CT), 4 underwent renal artery selective embolization (RAE), of which 2 cases were emergency RAE within 7 days after RAPN and the other 2 were prophylactic RAE 8 or more days after RAPN. In 98 patients examined for the clinical course of asymptomatic RAP managed by surveillance, excluding the 2 who underwent emergency RAE, routine CE-CT was performed at 7 days, 1 month and 3 months after RAPN. Factors influencing the occurrence of RAP among these 98 patients, including the 2 who underwent emergency RAE and excluding the 2 who underwent prophylactic RAE, were analyzed by logistic regression analysis.

Results

Median [interquartile range (IOR), range] observation period, age, radiographic tumor size, and maximum diameter of RAP were 20.8 (23.9, 3.0–57.6) months, 63 (18, 22–84) years, 23 (11, 9–48) mm, and 6.6 (5.2, 3.0–16.0) mm, respectively. CE-CT detected 28 RAPs in 23 (23.0%) of 100 patients by 7 days after RAPN and routine CE-CT detected 25 RAPs in 21 (21.4%) of 98 patients excluding 2 who underwent emergency RAE at 7 days after RAPN. RAP was diagnosed by routine CE-CT in 21 (21.4%), 1 (1.0%), and 0 (0%) patients at 7 days, 1 month, and 3 months after RAPN, respectively. In univariate analysis, age [odds ratio (OR) 0.144: 69–84 vs. 22–56 years old, P=0.0179], R.E.N.A.L [radius (tumor size as maximal diameter), exophytic/endophytic properties of tumor, nearness of tumor deepest portion to collecting system or sinus, anterior/posterior descriptor and location relative to polar line] nephrometry score (OR 1.374, P=0.0382), warm ischemic time (OR 1.085, P=0.0393), and renorrhaphy time (OR 1.055, P=0.0408) were significantly associated with the occurrence of RAP. In multivariate analysis, only age (OR 0.124, P=0.0148) was a significant factor.

Conclusions

Asymptomatic RAP up to 15 mm in diameter resolved spontaneously 3 months after RAPN. Young age (under 56 years) may be a factor in the development of RAP.

Assessment of surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy for ≥T1b renal tumours

PURPOSE

To assess the surgical outcomes of off-clamp open partial nephrectomy without renorrhaphy. In the era of robot-assisted surgeries, open partial nephrectomy remains a surgical option for  ≥ T1b renal tumours. Although the necessity of renal pedicle clamping and renorrhaphy in open partial nephrectomy for larger tumours remains to be discussed, reports on this issue are rare.

METHODS

Twenty-seven open partial nephrectomies for  ≥ T1b renal tumours were performed without renal pedicle clamping or renorrhaphy. A soft coagulation system was used to control bleeding from the resection bed. Surgical results, complications, and predictors of perioperative estimated glomerular filtration rate (eGFR) preservation at 1 month and 3 months after surgery were analysed.

RESULTS

The median estimated volume of blood loss was 420 mL. The rates of perioperative eGFR preservation were 88.9 and 87.3% at 1 and 3 months after surgery, respectively. Tumour size was an independent predictor of perioperative eGFR preservation at 1 month after surgery, whereas age and exophytic/endophytic properties of the tumour were independent predictors of perioperative eGFR preservation at 3 months after surgery.

CONCLUSION

Open partial nephrectomy without renal pedicle clamping or renorrhaphy could be safely performed for  ≥ T1b renal tumours, even when tumours were entirely endophytic and located close to the renal pedicle. Mild perioperative eGFR reduction was observed. Although surgical indications should be carefully considered in these cases, off-clamp open partial nephrectomy without renorrhaphy is a feasible procedure for patients with  ≥ T1b renal tumours.

Mid-term outcome of transarterial embolization of renal artery pseudoaneurysm and arteriovenous fistula after partial nephrectomy screened by early postoperative contrast-enhanced CT

Purpose

To retrospectively evaluate the mid-term outcome of transarterial embolization (TAE) of renal artery pseudoaneurysm (RAP) including arteriovenous fistula (AVF) after partial nephrectomy screened by early postoperative contrast-enhanced CT (CE-CT).

Materials and methods

Eighty-two patients (7.0%) who underwent TAE after partial nephrectomy were reviewed, from 1166 partial nephrectomies performed over 6 years. In 18 patients (22.0%), TAE was performed emergently on the median postoperative day (POD) seven. In the remaining patients, elective TAE was performed on the median POD six for RAP detected by early postoperative CE-CT or that emerged on follow-up CE-CT.

Results

In one patient (1.2%), TAE was performed twice because one of two RAPs could not be embolized during the first TAE, being successfully embolized at the second TAE after readmission with hematuria. Otherwise, no bleeding recurrence or RAPs were observed during the median 1354 follow-up days. Thus, the primary and secondary success rates of TAE were 98.8% (81 of 82 patients) and 100% (82 of 82 patients), respectively. On angiography, the average number of lesions was 1.7 ± 0.9 and the average RAP size was 12.8 ± 6.0 mm. The shapes of the lesions varied: oval-round 60, oval-round + AVF 36, irregular + AVF 14, AVF 12, irregular 10, disruption 4, and extravasation 3. No major complications were observed. The median inpatient days after TAE were two. No estimated glomerular filtration rate deterioration was observed (64.6 ± 18.6 vs. 64.2 ± 18.4 mL/min/1.73 m², p = 0.902).

Conclusion

TAE is largely effective and safe for treating bleedings or RAPs, including AVFs, after partial nephrectomy, as screened by early postoperative CE-CT.

Lower Incidence of Postoperative Acute Kidney Injury in Robot-Assisted Partial Nephrectomy Than in Open Partial Nephrectomy: A Propensity Score-Matched Study

Background: Acute kidney injury (AKI) after partial nephrectomy is attributed to parenchymal reduction and ischemia, but the extent of its effect remains unclear. This study aimed to compare the incidence of postoperative AKI among surgical modalities, robot-assisted partial nephrectomy (RAPN), laparoscopic partial nephrectomy (LPN), and open partial nephrectomy (OPN), and to evaluate the validity of RAPN by comparing it with LPN and OPN in terms of postoperative AKI, perioperative complications, and long-term renal function. Patients and Methods: Patients who underwent RAPN, LPN, and OPN for renal tumors at our institutions between 2004 and 2018 were retrospectively analyzed. RAPN and LPN were performed under warm ischemia and OPN under cold ischemia. En bloc hilar clamping was employed for LPN and OPN and arterial clamping for RAPN. AKI was defined as % decrease in estimated glomerular filtration rate (eGFR) >25% from preoperative eGFR to postoperative nadir eGFR. Multivariate regression analysis was used to test associations of AKI with perioperative factors. Then, we compared the incidence of AKI with two propensity score-matched cohorts: RAPN vs OPN and RAPN vs LPN. Results: This study included 1762 cases (RAPN: 959, LPN: 215, and OPN: 588). After matching, 147 cases each from RAPN and LPN groups and 368 cases each from RAPN and OPN groups were selected. RAPN had shorter warm ischemia time than LPN, lower incidence of AKI, and lower % decrease in eGFR after 6 months. RAPN had a shorter ischemia time and a lower incidence of AKI than OPN, although the % decrease in eGFR after 6 months did not differ significantly. Conclusions: AKI incidence was lower in RAPN than in LPN or OPN, which may be due to the shorter ischemia time or clamping of only arteries in RAPN. Although long-term renal outcomes did not differ between RAPN and OPN, RAPN can help prevent AKI. This supports the validity of RAPN for patients with chronic kidney disease.

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.