How to improve outcome in nephron-sparing surgery: the impact of new techniques

Abstract

Purpose of reviewNephron-sparing partial nephrectomy is the state of the art for localized small renal mass and it is gaining attention also for more advanced cases. In the present narrative review, we discuss the new developments that have occurred in the advancement of this approach over the past few years.Recent findingsOff-clamp, selective/superselective clamp and early-unclamping techniques are safe and feasible approaches, with potentially superior functional outcomes, and noninferior complications rate and oncological outcomes, when compared with main artery clamping. Renorrhaphy must preserve the physiological vascularization of residual parenchyma. Running sutures, particularly using barbed wires, shorten the operating and ischemia times. A further advantage could derive from avoiding a double-layer suture. Transperitoneal robot-assisted partial nephrectomy (RAPN) and retroperitoneal RAPN can be considered equivalent in terms of perioperative morbidity, functional and oncologic outcomes, regardless of tumor's location, thus the choice of the approach should be driven by the surgeon's expertise. Future improvements should be introduced by the single-port robotic surgery, which seems to be safe and feasibly also in an off-clamp manner.SummarySignificant advances have recently been achieved in nephron-sparing surgery technique. However, future studies with standardized reporting of these new techniques are needed to assess the real impact of them on early and long-term functional outcomes.

Risks and benefits of partial nephrectomy performed with limited or with zero ischaemia time

“…Indeed, renorrhaphy is considered one of the aspects of surgery that can be modified in order to optimize surgical features and preserve renal function after PN. New techniques (e.g., running, barbed, single‐layer suture) may facilitate intracorporeal suturing during PN and minimize WIT and EBL [5], the two main outcomes of our study. At our institution, various renorrhaphy techniques have been adopted over the years.…”

“…Furthermore, with the advancement of surgical techniques, an increase in PN use over time has been recorded and recent guidelines recommend offering PN also to patients with larger masses (cT2 tumours), especially in cases of solitary kidney or chronic kidney disease, if technically feasible [3,4]. However, in the era of minimally invasive surgery, several studies have focused on the most relevant key determinants of patient outcomes after surgery, with the aim of improving surgical technique and achieving better surgical and functional outcomes [5,6]. In the case of PN, various selective clamping and no-clamp techniques have been investigated for many years [5][6][7][8][9], given that renal ischaemia is one of the most important drivers of renal function impairment after PN [6,10].…”

“…However, in the era of minimally invasive surgery, several studies have focused on the most relevant key determinants of patient outcomes after surgery, with the aim of improving surgical technique and achieving better surgical and functional outcomes [5,6]. In the case of PN, various selective clamping and no-clamp techniques have been investigated for many years [5][6][7][8][9], given that renal ischaemia is one of the most important drivers of renal function impairment after PN [6,10]. Furthermore, the debate regarding the acceptable duration of warm ischaemia time (WIT) is still ongoing among urologists, even though growing evidence suggests that the duration of ischaemia time and type of ischaemia have far less influence on postoperative renal function compared to other factors such as patient comorbidities and residual renal parenchym after surgery [6,[11][12][13].…”

Ipsilateral synchronous papillary and clear renal cell carcinoma: A case report and review of literature

“…Both laparoscopic, robotic and partial nephrectomy for multiple lesions of ipsilateral renal tumors have been reported[ 14 - 17 ]. Some studies have compared the two main surgical options for managing this subset of patients, and similar tumor-specific survival was observed for patients treated with nephron sparing surgery (NSS) and radical nephrectomy[ 18 - 21 ]. Regardless of which surgical mode is selected, the right balance between oncological control and renal function preservation should be considered.…”

Editorial: Standard and future in the treatment of renal cell carcinoma

“…Last, but not least, despite the recent emerging developments in systemic therapy, new techniques and surgical strategies are used to remove kidney tumors with a maximum of organ preservation. As surgical removal of the primary tumor is mostly the first step in RCC treatment the improvements in nephron sparing surgery and the impact of new techniques are a prerequisite in RCC treatment as described by Cignoli et al [12].…”