Our surgical technique in clampless laparoscopic partial nephrectomy (LPN) for renal tumours: “we just need a centimeter”

Maurizio Fedelini1, Francesco Chiancone1, Riccardo Giannella1, Clemente Meccariello1, Luigi Pucci1, Paolo Fedelini1
  • 1 AORN A. Cardarelli, U.O.S.C. Urologia (Napoli)

Objective

As time goes by, renal tumours surgery has had a trend towards parenchymal sparing and minimal invasive approach. It has been always debated what are renal tumours who are fit and unfit for this kind of surgery. Most recent guidelines suggest as limit for partial nephrectomy (PN) 7 cm of highest diameter of tumour (t1b tumours) (1). In any case the complications and the outcomes of partial nephrectomy is associated with the treatment center’s learning curve and surgeon's experience, and is correlated with the anatomical features of each case (2).
The aim of our study was to describe our technique in clampless LPN analyzing the intraoperative and postoperative complications of patients who underwent this procedure at our institute and the feasibility of our technique.

Materials and Methods

From January 2005 to December 2015, 265 patients underwent clampless LPN for a renal tumour at our institution. According to R.E.N.A.L (radius; exophytic/endophytic; nearness; anterior/posterior; location) NS (nephrometry scoring), 119 patients had low tumour complexity (score 4-6), 77 patients had moderate tumour complexity (score 7-9) and 69 patients had high tumour complexity (score 10-12).
Intraoperative and postoperative complications have been classified according to standardized reporting systems such as the Satava (3) and the Clavien-Dindo system (4).
In our technique we perform a clampless LPN without isolation of the renal pedicle except where required by specific technical necessity like intrahilar or perihilar tumors. A transperitoneal approach was used in all cases except for three cases (retroperitoneal approach). We usually isolate the tumour and surrounding fat, with a small portion (about one centimeter) of healthy parenchyma around its circumference, in order to control potential hemorrhages with transfixing parenchymal sutures. Usually we do not isolate all surface of the kidney. During the enucleation, a cleavage plane between pseudocapsule and normal parenchyma is usually created by monopolar scissors. Tumour is removed and hemostasis is controlled by using a bipolar dissector and “hem-o-lok®” clips. Complete hemostasis is usually achieved by “floseal® hemostatic matrix” and “surgicel®”. We perform a sliding hem-o-lok ® clips absorbable suture when we need to achieve a better emosthasis and for kidney reconstruction. Finally Gerota’s fascia is closed.

Results

Mean operating time was 116,8 minutes. Mean intraoperative blood loss was 220 millilitres (range 30-1200 millilitres). Intraoperative blood transfusions were not necessary (according to intraoperative blood count analysis). Postoperative blood transfusions were necessary in 8 out of 265 patients (3%). The mean length of hospital stay was 4,8 days (range 3-11 days). Drains were removed at a mean time of 4,3 after surgery (range 3-7). All operations were performed laparoscopically without conversion to open surgery.
6 out 265 patients (2,3%) experience intraoperative complications. 59 out of 265 patients (22,3%) experienced postoperative complications.
Table 1 shows in detail the intraoperative and the postoperative complications according to Satava classification and Clavien-Dindo classification, respectively.

Discussions

The robotic technology seems to allow a safer and more precise excision of complex renal tumours, which are most commonly removed using an open approach, with a technique that has a shorter learning curve and some technical advantages instead of classical laparoscopy (5). Our present results indicate that LPN is feasible and safe in experienced hands compared to open surgery also for high-surgical risk tumours when a robotic device is not avaible. Thompson RH et all. (2010) demonstrate that "every minute counts" when the renal hilum is clamped and warm ischemia time (WIT) is a well-known predictor of postoperative estimated glomerular filtration rate (eGFR) (6) . Based on this, it should be important to perform a clampless partial nephrectomy. We usually start the procedure superficially with an enucleoresection of the tumour, but when we are more deep the procedure becomes a simple enucleation, who has been previously described as a safe technique with oncologic equivalence to standard partial nephrectomy (7).
Postoperative complications rate was 22,3%. The rate is smaller (8,8%) if we do not include Clavien-Dindo I grade complications.
Despite this, estimated blood loss and overall postoperative complication rate were similar to the previous series in which both clamped and clampless LPN are enrolled (8).

Conclusion

Current evidences suggest that the amount of residual functional parenchyma represents an important factor that impacts postoperative renal function and that WIT is a well-known predictor of postoperative eGFR. As a consequence it is important to perform a clampless partial nephrectomy removing the danger risk of sacrificing healthy parenchyma. Clampless LPN without isolation of the pedicle is a feasible procedure for renal tumours with a low rate of intraoperative and postoperative complications in high volume centers. Moreover clampless LPN is a feasible procedure for renal tumours of high surgical complexity in high laparoscopic experience centers, when robotic devices are not available.

References

1- Simmons MN et all. Laparoscopic radical versus partial nephrectomy for tumors >4 cm: intermediate-term oncologic and functional outcomes. Urology 2009 May;73(5):1077-82.
2-Porpiglia F et all. Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve and tumour anatomical characteristics. BJU Int. 2013 Dec;112(8):1125-32. doi: 10.1111/bju.12317. Epub 2013 Aug 13.
3-Kazaryan AM et all. Morbidity assessment in surgery: refinement proposal based on a concept of perioperative adverse events. ISRN Surg. 2013 May 16;2013:625093. doi: 10.1155/2013/625093. Print 2013.4- Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R,Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009 Aug; 250 (2): 187-96.
5-Hanzly M et all. Learning curves for robot-assisted and laparoscopic partial nephrectomy. J Endourol. 2015 Mar;29(3):297-303. doi: 10.1089/end.2014.0303. Epub 2014 Oct 21.
6- Thompson RH, et all. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol. 2010 Sep;58(3):340-5. doi: 10.1016/j.eururo.2010.05.047. Epub 2010 Jun
7- Longo N, et all. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014 Jun;40(6):762-8.
8-Choi JE et all. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2015 May;67(5):891-901. doi: 10.1016/j.eururo.2014.12.028. Epub 2015 Jan 6.

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