What are considerations when performing a partial nephrectomy nephron-sparing surgery (NSS) to treat renal cell carcinoma (RCC)?

Updated: Mar 31, 2019
  • Author: Reza Ghavamian, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Several important principles exist for performing NSS for renal cell carcinoma (RCC). Early vascular control is the key for minimizing blood loss and for prompting renal hypothermia, when necessary, in cases in which it was not originally planned. Lower the surface and core renal temperature to minimize ischemic damage to the kidney. Intraoperatively, frozen section analysis of the resection margins is an important adjunct. Closure of the collecting system is mandatory to prevent fistula formation. In addition, inspect the entire remaining surface of the kidney to rule out multifocal RCC.

Do not hesitate to use temporary renal artery occlusion and hypothermia, even for relatively small lesions. This approach decreases intraoperative bleeding and, because of decreased tissue turgor, allows for palpation of the kidney for nonobvious intraparenchymal lesions that are not readily identifiable when the kidney is perfused. It also allows for better dissection of tumors, especially centrally located tumors, and assessment of the extent of involvement of contiguous intrarenal structures. Usually, only the renal artery is occluded, except in large centrally located tumors, in which the renal vein can be occluded to minimize bleeding and to allow for easier dissection and reconstruction.

Some surgeons have used intraoperative ultrasonography for evaluation of multifocality in select cases when preoperative imaging studies are equivocal or intraparenchymal nonpalpable tumors are suggested. In situations in which complex cystic lesions are encountered, ultrasonography can further characterize the lesion at the time of surgery. Ultrasonography can guide the incision in the renal capsule and identify the shortest and easiest access to the lesion that compromises and sacrifices the least amount of normal parenchyma. In one recent study, intraoperative ultrasonography did not add to preoperative CT scan or intraoperative inspection with regards to determining multifocality, but it did aid in determining the nature of intraparenchymal mass and the surgical approach.

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