Abbreviations (L)(O)PN (laparoscopic) (open) partial nephrectomy (L)RN (laparoscopic) radical nephrectomy CKD chronic kidney disease eGFR estimated GFR MSKCC Memorial Sloan Kettering Cancer Center MDRD Modification in Diet and Renal Disease SCORED screening for occult renal disease US ultrasound/ultrasonography R.E.N.A.L. Radius of tumour, Exophytic/Endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to the polar line (scoring system) ABC argon-beam coagulator EBL estimated blood loss LOS length of stay RFA radiofrequency ablation SEER Surveillance Epidemiology and End Results. INTRODUCTION Partial nephrectomy (PN) is under utilized in the USA and abroad, despite its virtues as an operation that achieves equivalent local tumour control to radical nephrectomy (RN) in T1 tumours (2.0 ng/mL) was 26% when no renal artery occlusion was used, 30% after warm ischaemia, and 41% after cold ischaemia.

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In this study, the cold ischaemia may have been selectively used in more challenging cases. The authors felt a limit of 20 min of warm ischaemia could decrease the risk of severe CKD in this highly susceptible patient population. Most Laparoscopic PNs (LPNs) are performed with no attempt at cold ischaemia although there are reports of cumbersome attempts at ureteric catheter placement and collecting system cold perfusion, renal artery cold perfusion directly or using temporary balloon occlusion, and placement of ice-slush laparoscopically.

Although, the precise degree of lasting renal damage caused by any form ischaemia is not known with certainty, most experts agree that working quickly in either warm or cold ischaemic states is in the patient’s best interest. Until a more precise serum or urinary marker for ischaemic renal injury is identified, the matter of ischaemic injury to the kidney during PN will remain unresolved.

A robust dialogue between minimally invasive and open surgeons concerning case selection (including patient age, solitary kidney, and preoperative eGFR) and optimum surgical approach based on the tumour location and size, and the anticipated ischaemic time required to resect the tumour, would be ideal in centres where expertise in both approaches exists as a means of maximizing both oncological and renal functional outcomes. In my mind, sensible recommendations at this time are as follows:.

If a tumour is in an exophytic location performing the PN (OPN or LPN) without renal artery occlusion is likely to cause the least renal injury;. If warm ischaemia is used during LPN, tumour resection should be completed in. Preoperative nomogram predicting 12-years metastasis-free survival based on clinical features combining data on 2517 patients from MSKCC and the Mayo Clinic (adapted from Raj et al. In the early experience with PN, surgeons would consider this operation only if the tumour was cortically based, exophytic, and without close proximity to the renal hilar vessels or encroachment upon the collecting system.

However, as the virtues of PN became increasingly apparent, surgical approaches to more complicated tumours became feasible. Decisions concerning whether a PN or an RN should be performed were largely based on the comfort level of the operating surgeon for encountering and repairing these vital renal structures. Recently, investigators from Fox Chase proposed a scoring system (R.E.N.A.L.

For Radius of tumour, Exophytic/Endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to the polar line) as a means for comparing of renal masses and comparing outcomes of different procedures. Examples of scoring in the RENAL system are as follows; tumours that were ≤4 cm are given 1 point, 2 points for 4–7 cm, and 3 points for 7 cm. Tumours that are ≥50% exophytic are assigned 1 point, tumours. a, Standard positioning in the flank position for a mini-flank surgical approach to the kidney (adapted from Diblasio et al. B, Mini-flank surgical incision, ≈8–10 cm, with incision above the 11th rib and in the space between the 10th ribs (adapted from Diblasio et al. C, Soft tissues of the retroperitoneal space are entered above the 11th rib (supra 11th space).

D, Retroperitoneal space is bluntly developed exposing peri-renal fat and gaining rapid access to the kidney. E, The ureter is isolated from retroperitoneal soft tissues and identified with a yellow vessel loop. a, The renal vein and renal artery (arteries) are carefully dissected from surrounding lymphatic soft tissues and identified by red (artery) and blue (vein) vessel loops. During cold ischaemia, a ‘bulldog’ vascular clamp is applied to the renal artery. B, Reno-protective ice slush is applied to the kidney with careful time keeping to accurately record the cold ischaemia time. Now that the kidney is completely mobilized, careful palpation and inspection of its entire surface is performed to confirm the presence of the tumour and seek any satellite lesions. All preoperative imaging is available in the operating room to confirm tumour laterality before starting the operation.

For patients with endophytic tumours that are not palpable or apparent on the surface of the kidney careful correlation between CT imaging and intraoperative US is required to precisely locate the tumour by measuring the CT distance from either pole in centimetres, marking the kidney surface with a marking pen, and then confirming the exact location with the intraoperative US before nephrotomy incision and tumour resection. We also routinely use intraoperative US to confirm the presence of the tumour, seek satellite lesions, assess the proximity to intra renal veins or branched renal vein thrombus and determine if there is tumour encroachment or invasion of the renal collecting system. For a purely exophytic tumour or in a patient with significant underlying CKD, resection of the tumour without renal artery occlusion is performed. For other patients with large, endophytic, or perihilar tumours who require renal artery occlusion, we always use reno-protective measures including mannitol infusion (12.5 g/200 mL of normal saline) and ice slush.

In no cases of OPN at our centre will we use renal artery occlusion without such reno-protective measures. Intraoperative US is routinely performed to locate endophytic tumours, assess kidney for satellite tumours, collecting system invasion, or branched renal vein thrombus invasion. Once the tumour is isolated with its surrounding perinephric fat, the renal cortex is scored using the electrocautery. Sharp scissor dissection is used with a careful eye to keep the plain of surgical dissection within the renal cortex (pink kidney tissue) and not get too close to the renal tumour and its pseudocapsule. If dissection is too close and renal tumour pseudocapsule is identifed, readjustment to a deeper plane of dissection is made. Once the renal sinus is entered beneath the tumour, 3–0 absorbable sutures are placed into small veins and arteries, or breaches in the collecting system to both secure these items as well as provide upward traction on the kidney, which effectively decreases venous bleeding as the kidney is now higher than the central venous pressure.

A later search for venous bleeding can be accomplished by simply dropping the kidney into the wound and then raising it again. Once the specimen is delivered, it is carefully inspected to be certain that no false planes of dissection occurred and that there is a complete covering layer of kidney and soft tissue around the specimen.

The deepest surgical margin of the specimen is marked with a silk suture to orientate the specimen, which is then is delivered to the pathology department fresh and in sterile condition. Frozen section of the deep margin and specimen can provide immediate reassurance to the surgeon and the family but is not essential in each case particularly if the surgeon, using loupes sees that the specimen is completely surrounded by normal kidney or intra-renal soft tissue.

With the aide of loupe magnification, defects in the collecting system and small vessels are easily identified and closed using 3–0 or 4–0 absorbable suture with special care taken to separately repair veins and arteries to decrease the risk of iatrogenic arteriovenous fistula (pseudoaneurysm) formation. The use of bulky and deep sutures (2–0) into bleeding areas of the renal sinus should be avoided as this can promote iatrogenic arteriovenous fistula formation. Endophytic tumours may be emanating from elements of the renal cortex facing the renal sinus and completely impalpable. In this setting, the tumour is located using intraoperative US and after renal artery clamping and the institution of reno-protective ice slush cold ischaemia, access to the renal sinus is achieved by going through the cortex preferably in a relatively avascular plane (Brodel’s line). Once in the sinus, the renal tumour is palpated and identified, and carefully resected with care being taken not to get too close to the tumour or enter its pseudocapsule. Once the tumour is removed, it should be carefully inspected to ensure it is completely intact. Similar careful repair of the renal sinus vessels and collecting system described above is performed.

On occasion, the resection plane may leave an intact renal papilla without corresponding collecting system for drainage. In this case, the argon-beam coagulator (ABC) is used to destroy the papilla to avoid urinary extravasation without a means of draining the system. We also use the ABC to coagulate the renal parenchymal surface throughout the resection bed. Once haemostasis is achieved and collecting system repairs completed, perinephric fat and haemostatic agents such as FloSeal TM (Baxter, Deerfield, IL, USA) and Surgicel TM (Johnson and Johnson, New Brunswick, NJ, USA) are then placed in the resection cavity.

Size zero chromic liver sutures are then placed between pledgets of Surgicel to re-approximate the edges of renal cortex and close the resection cavity. a, Kidney is split along avascular plane (Brodel’s Line) to gain access to renal sinus and endophytic tumour.

B, Endophytic tumour within renal sinus is identified and resected completely. C, Repairs are made in the collecting system and rents in renal sinus arteries and veins are repaired with absorbable sutures. D, ABC is used to control the cut surface of the renal parenchyma. E, Floseal and Surgicel are applied to the resection cavity to fill the potential space and achieve haemostasis. F, Atraumatic sutures (0-chromic liver needle) pledgeted with surgical are used to close the cut renal parechymal edges. The renal artery is unclamped and gentle pressure is applied to the kidney for 3–5 min. We ask anaesthesia staff to be certain that blood pressure is within normal range for the patient and then inspect the kidney for any arterial bleeding or venous oozing before initiating closure.

A closed suction Jackson-Pratt drain (Allegiance Healthcare, McGaw Park, IL, USA) is placed through a separate stab wound in the retroperitoneal space in a dependent position posteriorly if the collecting system is entered. For exophytic tumours excised completely without exposure to the renal sinus and collecting system elements, the drain can safely be omitted. The surgical incision is closed in two layers using no. 1 polydioxanone, and the skin incision is re-approximated using 4–0 absorbable sutures in a subcuticular fashion.

In our previously published series of 167 consecutive patients undergoing OPN ( n= 133) or ORN ( n= 34) from 2000 to 2003 using the supra-11th mini-flank incision, we reported that this approach can safely provide optimum anatomical exposure without rib exposure with decreased intraoperative estimated blood loss (EBL) and length of stay (LOS) as well as a better cosmetic result compared with traditional rib resecting open techniques. In the original OPN group, the median (range) LOS was 4.5 (2–8) days and the EBL was 375 (50–2000) mL.

At the median follow-up of 18 months, 3.6% of patients reported a bulge (no hernia but muscular atony) at the incision site, and one patient was diagnosed with an incisional hernia requiring surgical intervention. There were no intraoperative complications although one patient had a prolonged hospitalization due to a concomitant urinary fistula with a UTI, which also resulted in delayed removal of the drain. In an update of 280 additional cases of OPNs (April 2003 to January 2007) using the supra-11th mini-flank approach, the median (range) LOS decreased further to 4 (2–12) days with an EBL of 300 (50–3000) mL. There was one reported major intraoperative complication (bleeding), but it did not result in loss of the kidney. At a median follow-up of 8 months for this cohort, 1.8% of patients reported a flank bulge. Today we encourage early ambulation (walking a mile around the hospital ward on postoperative day 1), which makes a 2-day hospital stay achievable in most patients. Muscle atony/bulge at the incision site without hernia can be a disconcerting finding ameliorated or improved completely by exercises that passively twist the upper torso (using an exercise bar, broom or golf club), which thereby strengthens collateral muscle groups leading to resolution of the bulge.

For the rare flank hernia, open complex repair with synthetic mesh is more effective than attempted primary repair, which is much more prone to recurrence. The appropriate management of the ipsilateral adrenal gland during PN has created some confusion. Insight into this problem and an effective management scheme was recently described by Cleveland Clinic investigators who perform ipsilateral adrenalectomy only if there is a suspicious adrenal mass on preoperative imaging or if intraoperative findings suggest a direct tumour extension from an upper pole renal mass. Ipsilateral adrenalectomy was performed only in 48 of 2065 PNs (2.3%). There was direct extension of a renal cancer in only one patient, noncontiguous metastatic disease in two patients, and other adrenal pathology in three patients. In 42 patients (87%), the adrenal gland was benign despite the abnormal preoperative imaging appearance.

During long-term follow-up, 15 patients underwent subsequent adrenalectomy (0.74%) revealing metastatic disease in 11 patients, two of which were bilateral and two that were contralateral. The authors concluded that in the absence of abnormal preoperative imaging or obvious intraoperative findings, ipsilateral adrenalectomy is not necessary during PN. MINIMALLY INVASIVE APPROACHES TO THE SMALL RENAL MASS The development of minimally invasive laparoscopic renal tumour surgery and tumour ablative techniques, such as radiofrequency ablation (RFA) and cryoablation, has been ongoing for 19 years by committed investigators in the USA and abroad. The advantages of cosmetic incisions, decreased perioperative analgesic requirements, decreased hospitalization, and more rapid return to normal activity were emphasized in early publications and short-term oncological endpoints seemed equivalent to their open surgical counterparts. However, at centres with expertise in both open and minimally invasive surgery approaches for renal cortical tumours, published experiences have shown inconsistencies in the management of small renal tumours. Open surgeons were more likely to perform PN, and laparoscopic surgeons were more likely to perform RN. These reports suggested that minimally invasive surgery learning curves were being conquered by RN applied to small renal tumours (.

Minimally invasive PN can be done using laparoscopic and robot-assisted approaches but renal artery occlusion with warm ischaemia is usually used. As minimally invasive urological oncologists gain more experience and instrumentation, including robotic devices, continue to improve, coupled with further refinements in case selection, it is expected that complications related to LPN will decrease and the ability to effectively resect larger and increasingly challenging hilar tumours will increase. An expert laparoscopic surgeon from the Cleveland Clinic recently analysed his LPN experience from 1999 to 2008 and noted a transition from smaller more peripheral tumours in the early years to larger more central tumours. At the same time, warm ischaemia times decreased from 31.9 min to 14.4 min. In addition, overall complications and the adverse impact on renal function also declined.

This study clearly showed enhanced laparoscopic skills and improved results over time but the degree to which this is transferrable to lesser volume and lesser expert surgeons’ remains uncertain. For expert laparoscopic surgeons the early experience with robotic assistance indicates the procedure is feasible and safe but associated with longer warm ischaemia times compared with pure laparoscopic approaches. The ultimate goal of PN to achieve local tumour control and preserve maximum renal tissue will require careful case selection and robust dialogue between open and minimally invasive surgeons.

Renal tumour ablative methods, including percutaneous and laparoscopic approaches to RFA and cryoablation, are offered selectively to some patients with renal tumours that are exophytic and not encroaching upon renal hilar vessels or collecting system elements. Patients considered by many as ideal candidates for ablation are often very old or comorbidly ill individuals harbouring small renal tumours, the very patients ideally suited for active surveillance. Although the concept of non-surgical ablation is appealing, published reports have serious deficiencies including up to 40% of patients not having pre-ablation confirmation of tumour due to non-diagnostic or nonexistent biopsy, short overall follow-up, and high rates of tumour recurrence compared with PN ranging from 7.45 to 18.23-fold greater than PN for RFA and cryotherapy, respectively.

Additionally, because most studies lacked pathological confirmation to confirm the completeness of the ablation, it is not known whether changes in radiological images after ablation represent complete or partial tumour destruction or simply a renal tumour, partially treated and not in active growth. As described above, the Cleveland Clinic experience with difficult salvage operations after failed ablation leads to a high likelihood of RN as the final outcome in a patient population initially candidates for either active surveillance or PN, an outcome that now must be viewed as unfavourable from both oncological and renal functional points of view. Carefully designed ‘ablate and resect’ clinical protocols need to be done, much like those done in the 1990s for cryotherapy and localized prostate cancer, to determine the true effectiveness of these approaches. COMPLICATIONS OF PN Surgical complications related to PN historically were the major disincentive for many urologists for advocating its expanded use and relate to three major categories; bleeding, urinary fistula, and infection. Using a graded scale of complications in 15 categories describing over 163 unique complications, MSKCC investigators evaluated 361 (34%) patients undergoing PN and 688 (66%) patients undergoing RN from 1995 to 2002.

Procedure-related complications included urinary leak, acute renal failure, retroperitoneal haemorrhage, pneumothorax, adjacent organ injury and small bowel obstruction. Urinary fistula was defined as persistent urine leak lasting 7 days after PN or a collection requiring a percutaneous drain placement.

Complications were graded using a five-tiered system: grade 1, oral medication or bedside care; grade 2, i.v. Therapy or thoracostomy tube; grade 3, intubation, interventional radiology, endoscopy, or re-operation; grade 4, major organ resection or chronic disability; grade 5, death. In this study, 235 complications occurred in 180 patients (17%).

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Overall 55% and 31% of the complications were grade 1 and 2, respectively. There were three perioperative deaths (0.2%). PN was not associated with more complications compared with RN but PN did have more procedure-related complications (9% vs 3%) due mainly to urinary fistula with re-intervention rates of 2.5% for PN vs 0.6% for RN. All but one re-intervention involved endoscopy or interventional radiology. Neither tumour size, tumour location (central vs polar) or imperative vs elective indication was associated with complications of PN.

Multivariate analysis indicated that operative duration and solitary kidney were significantly associated with procedure-related complications of PN. Using the same five-tiered complications grading scale, Cleveland Clinic minimally invasive surgeons evaluated 200 consecutive patients undergoing LPN using either transperitoneal or retroperitoneal approaches for cases performed between 2003 and 2005. The mean tumour size was 3 cm and a mean parenchymal depth of 1.8 cm. In all, 35 patients (17%) had a complication. Of these, 29% and 42% were grade 1 and 2, respectively.

Conversion to ORN (two patients) and LRN (one patient) was an uncommon event. The median (range) warm ischaemia time was 35 (8–60) minute. Compared to their initial experience with LPN in 200 patients, the authors felt that their increased experience with laparoscopic techniques and ability to resect more complicated tumours based on size and location indicated that technical improvements in the operation were decreasing the overall complications by 44%, urological complications by 56%, and haemorrhagic complications by 53%. In another analysis of their overall LPN experience from 1999 to 2006, the same group showed an increasing willingness to resect complex, large, and central renal tumours while overall, urological, and non-urological complications significantly decreased.

Risk factors associated with complications after LPN were prolonged ischaemia, increased intraoperative EBL, and solitary kidney status. As the experience with PN was increasing, particularly from centres of excellence with a strong experience in both OPN and LPN, careful case selection and preoperative surgical planning were emerging as the critical factors that affected outcome. The Cleveland Clinic group reported their experience in 169 patients with T1 (48 h. Overall, 21 patients (13.3%) had urine leakage. Factors associated with a greater likelihood of urine leak included larger tumour size, endophytic tumour location and repair of collecting system at the time of tumour resection. Factors not associated with urine leak included number of tumours resected, EBL, ischaemia time, body mass index, age, or other surgical complications.

The median duration of the leak was 20 days. Most urine leaks resolved with prolonged drainage, but 10 patients (38%) required a secondary intervention including a ureteric stent (eight patients) and percutaneous nephrostomy (two patients). No RNs or surgical re-explorations were required. In a larger study, MSKCC investigators analysed 1118 PNs defining persistent urinary leak as that lasting for 2 weeks or a patient that represents after drain removal with a urinoma requiring percutaneous drainage. In all, 52 patients developed a postoperative urinary fistula (4.4%) with persistent leak accounting for 4% and delayed fistula presentation accounting for 0.4% of cases. Factors associated with urine leak were larger tumours (3.5 vs 2.6 cm), more EBL (400 mL vs 300 mL), and longer ischaemia time (50 min vs 39 min).

Overall, 36 patients (69%) resolved the fistula without intervention while 16 patients (31%) underwent a secondary procedure including stent (eight patients) and another drain (two patients). No patient lost their kidney or required a nephrectomy to manage the fistula. Urologists often debate in conferences whether closed suction or Penrose drainage is preferable after PN.

MD Anderson surgeons evaluated 184 patients undergoing 197 PNs at their centre, with drainage type based solely on surgeon preference. A Penrose drain was used in 74 patients (37.6%) and a closed-suction drain in 123 patients (62.4%). Clinical characteristics between the groups were similar and mean tumour size was 3.1 cm. There was no significant difference in the mean duration of drainage between those receiving a Penrose drain (7.1 days) and those receiving a closed-suction drain (7.8 days). In addition, there was no significant difference in postoperative complications between the groups.

On a practical level when faced with a persistent urinary leak, I encourage patients to eat ‘three square meals a day’, rest, and exercise in hopes of speeding natural wound healing. If urine leak continues for more than 6–8 weeks without any sign of gradual decline, a cystoscopy and retrograde pyelogram should be done to exclude the possibility of distal ureteric obstruction.

A disconcerting finding on such a study could be the finding of a normal pyelocalyceal system yet persistent urinary drainage. In this case, it must be assumed that there is an excluded renal papilla without a corresponding calyx that is causing the leak.

In this circumstance, the leak may take several months to resolve until that papilla is no longer functional. Retrograde pyelogram showing leakage of contrast from a middle pole calyx into perinephric drain.

An internal double stent was used to facilitate closure of the urinary fistula. Pseudoaneurysm or iatrogenic arteriovenous fistula forms when surgical repair of vascular rents fuses arteries and veins with the occurrence of direct communication between the two. On rare occasions, a palpable thrill can be noticed during the closing of a PN. In this case, the situation needs to be addressed immediately with either re-exploration of the PN bed and ligation of the communicating vessels or completion by RN. Delayed postoperative bleeding with perinephric haematoma can present with pain, gross haematuria, and hypotension, flank mass, or flank discoloration from dissecting blood through the healing wound.

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After appropriate resuscitation, CT renal protocol is used to make the diagnosis. This will show arterial blood is pooling in a closed space with or without perinephric haematoma, a finding which should initiate an urgent request to interventional radiology for a diagnostic and therapeutic selective renal artery angiogram and coil embolization. The interventional radiologist should make every effort to occlude a tertiary and quaternary branches of the renal artery as close to pseudoaneurysmal pocket as possible to limit collateral damage to viable, healthy renal tissue. Cohenpour et al.

Reported five such pseudoaneurysms (four after OPN, one after LPN) which presented 1–21 days after PN. Selective coil embolization was successful in four of the five cases and RN was required in one case. Careful surgical technique during OPN or LPN with avoidance of deep haemostatic ‘bites’ with large needles into the renal sinus will greatly diminish the likelihood of this complication. a, Renal protocol CT showing postoperative pseudoaneurysm of the left kidney with perinephric haemorrhage.

B, Selective angiogram showing pseudoaneurysm (iatrogenic arteriovenous fistula) of a tertiary branch of an upper pole renal artery. C, Successful coil embolization of the feeding arterial branch with subsequent complete resolution of the pseudoaneurysm. PN IS UNDER-UTILIZED In 2009, it is estimated that 57 760 patients will develop renal cortical tumours in the USA of which ≈70% are incidentally detected at a tumour size of ≤4 cm. Over the last 10 years, despite the well-described oncological and medical arguments in the contemporary literature supporting PN as the ideal treatment for such small renal masses, the urological oncology community continued to use RN as the predominant treatment of the T1 renal mass. Investigators took a cross-sectional view of clinical practice using the Nationwide Inpatient Sample; they reported that only 7.5% of kidney tumour operations in the USA 1988–2002 were PNs. Using the Surveillance Epidemiology and End Results (SEER) data base, investigators from the University of Michigan reported from 2001, only 20% of all renal cortical tumours of 2–4 cm were treated by PN and using the SEER database linked to Medicare claims, MSKCC investigators reported a utilization rate of only 19% for T1a tumours (≤4 cm). Interestingly and for uncertain reasons, women and elderly patients are more likely to be treated with RN.

Many urologists think a ‘quick’ RN in an elderly patient would expose the patient to fewer postoperative complications than would a PN. However, MSKCC investigators evaluated age and type of procedure performed in 1712 patients with kidney tumours and found that the interactive term was not significant indicating a lack of statistical evidence that the risk of complications associated with PN increased with advancing age. Furthermore, no evidence was reported linking age to EBL or operative duration. Given the advantages of renal functional preservation, the authors concluded that elderly patients should be perfectly eligible for PN. Although the urology literature has a great many articles written concerning the use of laparoscopy techniques to resect kidney tumours, the penetrence of LRN according to the National Inpatient Sample from 1991 to 2003 was only 4.6% with a peak incidence of 16% in 2003.

This data indicates clearly that the bulk of ‘kidney wasting operations’ are still being done by the traditional open surgical approach. In England, a similar under-utilization of PN was reported in 2002 with only 108 (4%) PNs out of 2671 nephrectomies performed. Investigators at MSKCC tracked nephrectomy use in 1533 patients between 2000 and 2007 excluding patients with bilateral tumours and tumours in a solitary kidney, and including only patients with an eGFR of 45 mL/min/1.73 m 2. Overall 854 (56%) patients underwent PN and 679 (44%) underwent RN.

In the 820 patients with a renal tumour of ≤4 cm, the frequency of PN increased from 69% in 2000 to 89% in 2007. In the 365 patients with a renal tumour of 4–7 cm, the frequency of PN increased from 20% in 2000 to 60% in 2007. Despite a commitment to kidney-sparing operations by our group during this period, multivariate analysis indicated that PN was a significantly favoured approach for males, younger patients, smaller tumours, and open surgeons. Abouassaly et al. From the University of Toronto provided more insight into the under-utilization of PN problem by evaluating 7830 patients in the Ontario Cancer Registry from 1995 to 2004.

Of these, 7042 (89.9%) underwent RN and 788 (10.1%) underwent PN. In 2003, LRN was introduced to Ontario by surgeons in this province but LPN was not available.

The authors used a multinomial logistic regression model to relate the relative numbers of patients with ORN and LRN, and OPN to patient age, gender and surgery year. Using a segmented trend regression model, the authors showed a clear change in PN usage with time ( P= 0.001) such that the odds of PN increased by 18% per year before January 2003 (odds ratio 1.18, 95% CI 1.14–1.23) and subsequently decreased by 12% per year (odds ratio 0.88, 95% CI 0.75–1.02). In the multinomial regression model, age and surgery year but not gender were independently associated with PN.

This study also showed that elderly patients were more likely to undergo RN (by any technique) than PN. One can only speculate that the emerging publications describing the benefits of PN was initially appreciated by the Ontario surgeons but subsequently overwhelmed by the desire of the surgeons to integrate new surgical technology (LRN) into their practices, essentially conquering the technical learning curve on patients with small renal masses. The extent to which effective marketing by instrument makers, hospitals, and surgeons wishing to portray the most contemporary surgical techniques played in the reversal of PN utilization is not known. CONCLUSION The emergence of PN as an effective treatment for small renal masses is based on the following fundamental facts:. I. About 20% of renal tumours are benign and 25% are indolent with limited metastatic potential;.

II. PN and RN provide equivalent oncological control for tumours of ≤7 cm;. III.

RN is associated with the development of CKD and associated cardiovascular morbidity and mortality. Despite the clinical research supporting PN for the treatment of small renal masses, the procedure remains under-utilized in the USA and abroad, a situation the will be rectified only by enhanced educational and surgical training programmes. Problems unique to PN, including the best means to provide renal ischaemia during tumour resection and management of potential postoperative complications of bleeding, infection, urinary fistula remain of significant concern to urological surgeons whether the operation is performed using open or minimally invasive techniques. It is now clear that, despite the technical challenges associated with executing an effective PN, that local tumour control and preservation of renal function make it the surgical procedure of choice for the treatment of the small renal mass.

CONFLICT OF INTEREST None declared. QUESTIONS.

1Patients more susceptible to the adverse impact of ischaemia during PN include:. (a) elderly patients with a low eGFR prior to operation. (b) extensive blood loss during the operation.

(c) long duration of ischemia time. (d) all of the above. Answer: d. 2True or false: A mini-flank surgical incision is associated with partial resection of the 11th rib. Answer: False.

3True or false: In the absence of a radiological abnormality on preoperative imaging, the surgeon performing a PN does not need to remove the ipsilateral adrenal gland. 1 Vivek Venkatramani, Sanjaya Swain, Ramgopal Satyanarayana, Dipen J.

Bhayani and Robert S. Figenshau. Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO, USA Laparoscopic renal surgery is associated with reduced blood loss, shorter hospital stay, enhanced cosmesis, and more rapid convalescence relative to open renal surgery. Laparoscopic partial nephrectomy (LPN) is a minimally invasive, nephron-sparing alternative to laparoscopic radical nephrectomy (RN) for the management of small renal masses. While offering similar oncological outcomes to laparoscopic RN, the technical challenges and prolonged learning curve associated with LPN limit its wider dissemination. Robot-assisted partial nephrectomy (RAPN), although still an evolving procedure with no long-term data, has emerged as a viable alternative to LPN, with favorable preliminary outcomes.

This article provides an overview of the role of RAPN in the management of renal cell carcinoma. The clinical indications and principles of surgical technique for this procedure are discussed. The oncological, renal functional, and perioperative outcomes of RAPN are also evaluated, as are complication rates. Introduction While the gold standard treatment of renal tumors was previously radical nephrectomy (RN), investigation over the past decade has demonstrated the surgical feasibility and equivalent oncologic efficacy of partial nephrectomy (PN) for the management of small renal masses (SRM; ). With mounting evidence indicating that overtreatment of renal masses with RN is associated with increased risk of chronic renal insufficiency, cardiovascular events, and premature deaths (;; ), the American Urological Association guidelines now explicitly endorse PN as the standard of care for managing T1a renal tumors and as an alternative treatment option for T1b tumors. Reflecting this paradigm shift, PN utilization has increased considerably at many centers of excellence over the past decade, approaching 90% for T1a tumors at some centers.

With the rapid dissemination of minimally invasive technology within the urologic community, laparoscopic PN (LPN) and, more recently, robot-assisted PN (RAPN) have emerged as viable alternatives to open PN (OPN) for the management of suspected renal malignancy. The long-term oncological and functional outcomes of LPN are similar to those of OPN (; ), with the potential benefits of reduced blood loss (estimated blood loss, EBL), shorter hospital stay (length of hospital stay, LOS), superior cosmesis, and more rapid convalescence.

However, LPN remains technically demanding, necessitating substantial technical expertise to achieve adequate tumor resection and renorrhaphy while minimizing ischemia times. Despite the development of novel techniques to facilitate LPN, the protracted learning curve associated with this procedure has hindered its dissemination into general practices in the U.S. And may, indeed, contribute to the underutilization of PN. Among its potential advantages, robotic technology offers high-definition three-dimensional visualization, a broad range of wristed-instrument motion, and scaling of surgeon movements. RAPN appears to have a shorter learning curve than LPN and, accordingly, may facilitate and promote the utilization of minimally invasive nephron-sparing surgery (NSS). We review the technique and outcomes of RAPN, assessing its current role and future prospects for the management of renal masses.

Set Up For the inexperienced robotic renal surgeon, judicious patient selection is critical. The lack of haptic feedback and reliance on the bedside assistant can present challenges unique to RAPN. Patients ideally suited for initial RAPN procedures include those with non-hilar, exophytic T1a lesions, uncomplicated vascular anatomy, and a normal contralateral kidney. Equipment Robot-assisted partial nephrectomy is performed using the da Vinci surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA).

Three robotic instruments are frequently used during RAPN – the Monopolar Curved Scissors in the dominant hand and ProGrasp forceps in the non-dominant hand; these are exchanged for robotic needle drivers during renorrhaphy. The ProGrasp’s blunt tips are suited for dissection of vessels and tumor and can be used to apply robotic bulldog clamps (Scanlan International, St. Paul, MN, USA) and manipulate the robotic ultrasound probe, if needed.

The PK (PlasmaKinetic) dissecting forceps, Maryland bipolar forceps, and robotic hook are other potentially useful instruments, which can aid in precise dissection and cauterization of small vessels. The scrubbed assistant employs conventional laparoscopic instruments to provide suction and countertraction via the assistant port. The fourth arm can be used with a retracting device to improve exposure, although instrument collisions may increase with its use, especially in patients with small torsos. Patient Positioning and Port Placement Patients undergoing transperitoneal RAPN are placed in a 75° modified flank/lateral decubitus position with the pathologic side up. A 90° full flank/lateral decubitus position is used for retroperitoneal RAPN (;; ). The transperitoneal approach is the most commonly used approach for RAPN. The most widely utilized transperitoneal camera/trocar configuration places the camera medial and superior to the umbilicus; a 30° downward-angled lens is used.

Two 8-mm trocars for the robotic arms are placed just cephalad of the anterior superior iliac spine and inferior to the costal margin in the mid-axillary line. A 12-mm assistant port is placed in the mid-line in either the upper or lower quadrant, depending on tumor location and surgeon preference.

If a fourth robotic arm is used, an additional 8-mm trocar is placed laterally, triangulated between the two other robotic trocars (; ). The robot is docked posterior to the patient. Access for retroperitoneal RAPN is obtained through a 1.2-cm skin incision just inferior to the tip of the 12th rib. The flank muscle fibers and thoracolumbar fascia are bluntly split, and the surgeon’s fingertip creates a potential space between the psoas muscle and Gerota’s fascia; this space is further expanded by injection of 800 mL of air into the retroperitoneum through a balloon dilator.

The camera port is then placed at the site of the balloon dilator. Generally, only two additional working ports, triangulated with the camera at an obtuse angle to reduce instrument collisions, are required. If a fourth robotic arm is used, the peritoneum is pushed medial to the belly of the rectus in order to expand the retroperitoneal workspace, and the fourth arm is placed anteriorly in that location. An assistant port is placed in the lower quadrant (; ). The robot is docked anterior to the patient. Surgery Depending on tumor location, patient surgical history, and surgeon preference, a transperitoneal or retroperitoneal approach is selected. While safe and effective in experienced hands, the retroperitoneal approach is potentially more challenging due to its confined workspace and relatively fewer anatomic landmarks.

Lesion Excision Following tumor exposure, its precise borders are delineated, often under intraoperative ultrasound guidance. The newly developed robot-controlled ultrasound probe (Aloka, Tokyo, Japan) allows full surgeon control of intraoperative imaging. TilePro software integration, included in newer robotic platforms, allows for real-time picture-on-picture display of radiographic images on the console screen, thus facilitating the mapping out of the dissection. Traditionally, renal hilar vessels are clamped – either individually (starting with the artery) using laparoscopic bulldog clamps or en bloc using a laparoscopic Satinsky clamp – prior to tumor excision; the latter requires placement of a dedicated port. Recently developed “robotic bulldog clamps” provide the surgeon additional autonomy, in lieu of having to relegate the delicate task of hilar occlusion to the assistant. The tumor is excised sharply with a rim of normal renal parenchyma. The assistant applies counter-traction with the suction device to enhance visualization during tumor excision.

Repair Using robotic needle drivers, renorrhaphy is traditionally performed in two layers. A deep-layer closure of the resection bed, which includes repair of large blood vessels and collecting system defects, is first performed with a poliglecaprone 25 or polyglactin suture in a running fashion. This is followed by an outer-layer closure of the renal capsule, performed using larger absorbable sutures and needles. The Washington University technique of “sliding-clip renorrhaphy” – widely adopted as a preferable alternative to the traditional tied-suture renorrhaphy – relies upon the use of Weck Hem-o-Lok clips, placed on either side of the defect and then slid into place by the surgeon, to exert tension upon the repair.

The Hem-o-Lok clips are generally reinforced with LapraTy clips to prevent backsliding of the clips. This technique is ideally suited for RAPN, as the robotic instrumentation affords the surgeon the requisite precision in dictating the degree of tension placed on the repair, effectively eliminating the need for placement of surgical bolsters in the renal defect to achieve tight closure. Techniques to Minimize Warm Ischemia As minimally invasive techniques for achieving renal hypothermia during renal hilar clamping have failed to gain widespread clinical application, RAPN is generally performed under conditions of “warm ischemia.” In recognition of the potential adverse effect that even limited warm ischemia time (WIT) may have on kidney function (;; ), multiple investigators have compared WIT during RAPN vs. While several earlier studies found no significant difference in WIT between RAPN and LPN (;; ), a recent study comparing 129 patients who underwent RAPN and 118 patients who underwent LPN demonstrated significantly reduced WIT in the RAPN group (19.7 vs. By simplifying the renorrhaphy, while minimizing reliance on the surgical assistant, the sliding-clip technique, as described above, has been shown to substantially reduce WIT during RAPN, compared to tied-suture renorrhaphy. Precluding the need for additional “anchoring” LapraTy clips, the more recent application of barbed suture to facilitate tight parenchymal closure during sliding-clip renorrhaphy may further decrease WIT (; ). Other variations in surgical technique previously described for OPN and LPN have also been applied to RAPN in an effort to minimize or eliminate WIT.

Some have adopted an “early unclamping technique,” clamping the renal hilum only during tumor resection and while suturing large vessels/collecting system at the resection base. Others have performed “selective renal parenchymal clamping,” clamping regional blood vessels only in the area of planned excision (; ). More recently, some have performed RAPN without any clamping of the renal hilum, suggesting that off-clamp RAPN can be safely performed in carefully selected patients (;,).

Our initial experience with off-clamp RAPN at Washington University demonstrates favorable renal functional outcomes with this technique (,). Nevertheless, several studies have failed to demonstrate long-term improvement in renal functional outcomes after any modification of clamping technique or in the absence of renal hilar clamping (;; ). Further studies will be needed to establish the efficacy and reaffirm the safety of these surgical approaches.

Complications Early series of RAPN reported complication rates ranging from 0 to 20%. A contemporary study of 886 consecutive cases of RAPN performed at five U.S. Centers reported an overall complication rate of 15.6%, with intraoperative and postoperative complication rates of 2.6 and 13.0%, respectively. Postoperative complications were classified as Clavien grade I–II in 77.0% of cases and grade III–IV in 23.0%. RAPN was converted to OPN or LPN in 0.2% of patients and to RN in 0.5% of patients. There were no deaths. Table summarizes complication rates of various RAPN series (;;;;;;;;;;; ).

Reported complication rates of RAPN are comparable to those seen in OPN and LPN. For example, reported complications in 13.7 and 18.6% of patients undergoing OPN and LPN, respectively. A study by comparing outcomes of RAPN vs. OPN in 281 patients demonstrated similar major and minor complication rates in the two groups. Compared 129 patients who underwent RAPN with 118 patients who underwent LPN and found no significant differences in complication rates. Series comparing complication rates of RAPN and LPN are presented in Table (;;;;;; ).

In the following section, some of the more common and significant complications of RAPN are discussed. Hemorrhage Intraoperative ) multi-institutional analysis of RAPN complications demonstrated an intraoperative hemorrhage rate of 1.0%. (Hemorrhage was defined as bleeding requiring blood transfusion or therapeutic intervention.) Parenchymal bleeding during tumor excision may result from inadequate hilar occlusion or unrecognized accessory vessels. Pulsatile bleeding of a typically larger volume indicates an arterial source, while a lower volume ooze suggests a venous source. In the case of arterial bleeding, controlled anesthetic blood pressure reduction may enhance visualization, and temporary removal of the venous clamp may reduce parenchymal congestion. En bloc hilar clamping with a Satinsky clamp or a long bulldog clamp is another option.

Venous bleeding can often be mitigated by raising the pneumoperitoneum up to 18 mmHg. In contrast to the renal vein unclamping maneuver recommended for arterial bleeding, with venous bleeding, an additional clamp may be placed on the renal vein to minimize venous backflow. Inadequate sutured renal reconstruction may lead to bleeding after the renal hilum is unclamped. Direct pressure is immediately applied and the insufflation pressure increased while the renorrhaphy clips are re-tightened. Emergent open conversion or conversion to robotic total nephrectomy may be necessary for uncontrolled bleeding. Postoperative In our multi-institutional analysis of RAPN complications, we reported a postoperative hemorrhage rate of 5.8%.

Published postoperative transfusion rates for RAPN range from 3 to 10%, which are comparable to the 5.8 and 3.4% rates for LPN and OPN, respectively. Pseudoaneurysm or arteriovenous fistula formation may result in delayed postoperative hemorrhage, often presenting several weeks after discharge. Angiography and embolization are indicated for persistent bleeding and/or hemodynamic instability. Urine Leak Although initial urinary leak rates reported for RAPN ranged from 2 to 12.5% , ) more contemporary multi-center study of RAPN complications reported urine leakage (defined as urine extravasation identified radiographically or “persistently” increased drain fluid creatinine) in only 1.1% of cases; this rate is significantly lower than the 3.1 and 2.3% rates reported in LPN series (; ).

In the absence of obstruction distal to the leakage site, the majority of urine leaks will spontaneously resolve within several weeks. Retrograde placement of a ureteric stent may be indicated if conservative management fails. Results Taken together, single series (Table;;;;;;;;;;;; ) and comparative studies (Table;;;;;;; ) have demonstrated that RAPN can be performed safely and with acceptable oncological, functional, and perioperative outcomes. Nonetheless, carefully matched (ideally, randomized) comparisons of OPN, LPN, and RAPN with long-term follow-up are still required. The recent development of metrics for comparing renal mass complexity (e.g., R.E.N.A.L. Nephrometry score,; and PADUA score, ) may facilitate such comparisons.

Oncologic Outcomes Because RAPN is a novel and maturing technique, positive surgical margin (PSM) rates have often been reported as a surrogate for oncological control. A review of contemporary RAPN series demonstrated a cumulative PSM rate of 2.7% , which is comparable to the 2.9 and 1.3% rates previously reported for LPN and OPN, respectively. PSM rates in various RAPN series are depicted in Table (;;;;;;;;;;; ), while studies comparing PSM rates between RAPN and LPN are outlined in Table (;;;;;; ).

Early and intermediate outcomes of RAPN show excellent oncological control. In fact, a review of modern large RAPN series encompassing 1600 patients demonstrated only seven recurrences, a rate of. Reviewed by:, Cleveland Clinic, USA, University of Utah, USA Copyright: © 2013 Tanagho, Bhayani and Figenshau.

This is an open-access article distributed under the terms of the, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and subject to any copyright notices concerning any third-party graphics etc.Correspondence: Youssef S. Tanagho, Division of Urologic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA. E-mail: tanaghoy@wudosis.wustl.edu.