What is the role of minimally invasive procedures in partial nephrectomy nephron-sparing surgery (NSS)?

Updated: Apr 01, 2019
  • Author: Reza Ghavamian, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Expanding indications for minimally invasive renal surgery. Presented by Craig Rogers, MD, FACS, Henry Ford Hospital and Health System. Video courtesy of BroadcastMed (https://www.broadcastmed.com/urology/6585/videos/expanding-indications-for-minimally-invasive-renal-surgery).

With the advent of laparoscopy, the field of minimally invasive renal surgery is gaining wider acceptance. The use of laparoscopy provides a minimally invasive conduit to the delivery of certain treatment modalities (eg, cryotherapy, radiofrequency ablation [RFA]). Laparoscopic nephrectomy is feasible in experienced hands and is now an accepted modality for the treatment of renal cell carcinoma (RCC).

In an effort to reduce morbidity of open nephron-sparing surgery (NSS), laparoscopic partial nephrectomy has emerged as a viable alternative to open surgery. Hemostasis is the rate-limiting step in this procedure, especially for larger lesions. Various forms of energy and devices have been used to aid in hemostasis. Bipolar and monopolar cautery, harmonic scalpel, and argon beam coagulator have all been used. Various surgical hemostatic aids such as fibrin glue and BioGlue have also been used to aid in the closure and seal of the renal parenchymal defect. The challenge remains with the sizable renal tumor in which hilar control is necessary.

No reliable method of parenchymal cooling is currently available to allow sufficient time for excision of the tumor and closure of the defect. At centers of excellence, the open operation can be duplicated using hilar control with laparoscopic bulldogs and Satinsky forceps, sharp tumor excision, and suture repair and closure of the collecting system. This is a complex laparoscopic operation that requires expertise in expeditious intracorporeal suturing.

Various studies have compared the outcomes of laparoscopic partial nephrectomy to those of open NSS. In the Cleveland Clinic experience, the analgesic requirement, blood loss, average convalescence, and even surgical time (3 h vs 3.9 h) were lower in the laparoscopic group. [15] However, the warm ischemia time was 27.8 minutes vs 17.5 minutes. No kidney was lost because of warm ischemia, and the postoperative serum creatinine levels were similar (1.1 mg/dL vs 1.2 mg/). The laparoscopic group had 3 positive margin results as compared to none in the open group. In addition, fewer renal or urologic complications occurred in the open NSS group than in the laparoscopic group (2% vs 11%). Although laparoscopic partial nephrectomy with hilar control is promising, better techniques of renal cooling and intracorporeal suturing are necessary to decrease warm ischemia and decrease urologic complications.

Laparoscopic partial nephrectomy is an excellent choice for the incidentally detected small renal mass that is exophytic. In this scenario, in which the resection is more superficial, hemostatic agents such as fibrin glue (Tisseel, Baxter Healthcare Corporation, Irvine, Calif) and BioGlue can be used in addition to bipolar and argon beam coagulation. In these cases, especially when the tumor is not invading the collecting system, select superficial tumors require no parenchymal suturing.

Laparoscopic partial nephrectomy is a technically challenging procedure that requires surgical dexterity and advanced laparoscopic skills. To facilitate the learning curve, some authors have recently published their preliminary experience with robotic partial nephrectomy and have reported acceptable results. [16, 17]

Ficarra et al conducted a study using the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification and found that, after adjusting for the effects of surgeon experience, clinical tumor size, and upper collecting system repair, anatomical classification of anatomic tumor characteristics score for tumors were independent predictors of warm ischemia time and overall complications in patients who underwent robot-assisted partial nephrectomy. [18]

One drawback of the robotic approach for the surgically facile laparoscopist is that the operating surgeon is not in total control. The operator, from the robot console, has to rely on the proficiency of his or her bedside assistant in this time-sensitive operation. Certainly, most laparoscopic kidney surgeons do not view the surrender of total control as a positive in robotic partial nephrectomy.

A cost-comparison of open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), and robot-assisted LPN (RALPN) found that LPN results in shorter length of stay, making it more cost-effective than OPN. Lower instrumentation costs make LPN more cost-effective than RALPN despite the fact that RALPN results in shorter length of stay. [19]

The application of laparoscopy in treating renal lesions has generated interest in the delivery of other modalities such as cryotherapy and RFA. More data are available for cryotherapy. This modality can also be performed percutaneously, using MRI and CT guidance. The preliminary data are encouraging. During a mean follow-up period of 16 months, no patients in the series of Gill et al from the Cleveland Clinic had radiologic evidence of renal fossa, port site, or distant metastases. [20] In their series of 32 patients (34 tumors), no evidence of tumor was found at 3 and 6 months when a biopsy of the cryolesion was performed using ultrasound guidance. This was performed in 23 patients, 13 of whom had RCC diagnosed intraoperatively based on laparoscopic needle biopsy. Although not definitive or fool-proof, the short-term results are encouraging.

Another area of research is RFA, which is an evolving technology. Early data show excellent short-term and long-term tumor control in a porcine model. As with cryotherapy, additional studies and longer follow-up are needed.

These ablative procedures can be performed laparoscopically or percutaneously. An important limitation of these techniques includes the lack of pathologic specimens to allow for accurate histologic evaluation. As stated above, long-term results are largely unknown. Successful outcomes have been described as radiologic evidence of infarction, hemorrhage, reduction in size, or absence of growth on follow-up. Several investigators have expressed concern over tumor viability, especially at the periphery of the RFA lesion, based on treatment and immediate nephrectomy after RFA. Another limitation is the lack of long-term data. Only with 5- and 10-year data can we reliably compare the results with partial nephrectomy. Assessing recurrence based on enhancement on imaging or growth only is difficult. Biopsy of the ablated area is not reliable, as it samples a small area of the lesion.


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