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

Abstract

Abbreviations & Acronyms BMI = body mass index CI = confidence interval CKD = chronic kidney disease CT = computed tomography DM = diabetes mellitus DTPA = diethylenetetramine pentaacetic acid GFR = glomerular filtration rate IQR = interquartile range PN = partial nephrectomy RAPN = robot-assisted partial nephrectomy WIT = warm ischemic time Objectives: To investigate whether differences in surgical details during robot-assisted partial nephrectomy impact postoperative renal function. Methods: Patient, tumor and perioperative characteristics of 751 patients who underwent robot-assisted partial nephrectomy were analyzed with respect to the difference in ipsilateral glomerular filtration rate measured by diethylenetetramine pentaacetic acid renal scan. Detailed surgical methods defined for tumor excision (cutting vs splitting), hemostasis (suturing vs clipping) and renorrhaphy (continuous vs interrupted) were analyzed for early glomerular filtration rate decline and long-term recovery.Results: The glomerular filtration rate of the entire cohort decreased by 9.8 mL/min/ 1.73 m 2 (22%) at 3 months postoperatively, gradually increasing thereafter. The recovery slope was 1.7 mL/min/1.73 m 2 /year during a median follow-up period of 23.0 months. Early glomerular filtration rate decline was more pronounced in the cutting group (23.5 vs 20.1%, P = 0.009). Clipping was associated with less glomerular filtration rate decline throughout the observation period, and the recovery slope was also significantly higher (2.7 vs 1.1 mL/min/1.73 m 2 /year). In multivariate analysis, early decline was associated with age, preoperative glomerular filtration rate, parenchymal volume loss and ischemia >25 min. With respect to long-term recovery, suturing had the greatest adverse impact (b = À5.060, P < 0.0001, 95% confidence interval À7.709, À2.411) in addition to parenchymal volume reduction and early decline. In the propensity-matched cohort accounting for differences in tumor size and complexity, suturing was persistently associated with a significant glomerular filtration rate decline until >2 years after surgery. Conclusions: Hemostatic sutures during robot-assisted partial nephrectomy might interfere with long-term renal function recovery irrespective of parameters that determine the initial function change. As the splitting method reduces the use of sutures, modifying these details might help preserve renal function.

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

“…In recent years, robotic surgery has been rapidly accepted for a wide variety of surgical procedures due to its definite benefits, including three‐dimensional (3D) clear vision, suppression of physiological tremor and fine manipulations of forceps with a wide range of motion 3 . In the field of kidney surgery as well, utilization of robot‐assisted PN (RAPN) has markedly increased as the standard of care for clinical T1 tumors 4–6 . Furthermore, since the initial report by Klinger et al, 7 RARN has been considered a promising alternative to ORN or LRN, and the proportion of RCC patients undergoing RARN has significantly increased over the past decade 8–10 .…”

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

“…Renorrhaphy might damage intraparenchymal vessels and compress the renal parenchyma, which would lead to further devascularization of normal nephrons. 6 Our GasLESS PN also excluded renorrhaphy in principle, which may have contributed to further improvement in renal function preservation by avoiding this possible negative impact. In the present study, renorrhaphy was performed in 16 patients (4%) based on the intraoperative findings.…”

“…Renorrhaphy is another classic procedure to ensure hemostasis after tumor removal, and most surgeons consider renorrhaphy to be an essential step for PN. Nevertheless, it has been reported that suturing the renal bed might negatively affect postoperative renal function by devascularizing the normal renal parenchyma 6 . Previous studies also suggested that renorrhaphy may increase the risk of pseudoaneurysm by lacerating arterioles 7 .…”

“…Nevertheless, it has been reported that suturing the renal bed might negatively affect postoperative renal function by devascularizing the normal renal parenchyma. 6 Previous studies also suggested that renorrhaphy may increase the risk of pseudoaneurysm by lacerating arterioles. 7 In RAPN or laparoscopic PN, however, concern regarding the risk of hemorrhage after gas desufflation may cause surgeons to refrain from omitting renorrhaphy.…”

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

“…However, another meta-analysis showed no significant difference in the incidence of postoperative complications between SILR and DLR [28]. Hemostatic running sutures frequently performed during RAPN, especially deep in the renal medulla, may encircle the branches of vessels traveling in proximity [29]. Therefore, SILR is thought to significantly reduce the incidence of pseudoaneurysms as suturing the renal parenchyma during renorrhaphy helps prevent injury to the renal vessels [28].…”