Laparoscopic Partial nephrectomy - Recent operative advances

1. PARTIAL NEPHRECTOMY
- Dr ABHISHEK PANDEY

2. 1 – INDICATIONS
• AUA guidelines (2017) –
– Prioritize PN for cT1a renal mass
– Prioritize PN – solid / complex cystic (Bosniak 3/4)
renal masses in patients with –
• Solitary Kidney – Anatomic / Functional
• Bilateral tumors
• Known Familial RCC
• Pre-existing CKD or Proteinuria

3. – Consider PN – solid / complex cystic (Bosniak 3/4)
renal masses in patients with –
• Young Patients
• Multifocal masses
• Comorbidities likely to impact renal function – DM/HTN
• T1b & T2 tumors – good oncologic results, but with
increased risk of peri-operative complications*
• Mir MC, Derweesh I, Porpiglia F, Zargar H, Mottrie A, Autorino R. Partial Nephrectomy Versus
Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-
analysis of Comparative Studies. Eur Urol. 2017 Apr;71(4):606–17.

4. 2 – Patient Positioning
Modified Flank Full Flank
Used in (Approach) Transperitoneal Retroperitoneal
Flank up angle 45° 90°
Axillary Roll Not required Required
Neuromuscular Injury
•Rhabdomyolysis 0-5%
•Brachial plexus injury 1-3%
Reduced Risk

5. Modifies Flank Position – Operative side tilted up 45° using gel roll supporting back

6. Left Right Obese
Subcostal -
retraction
5mm subxiphoid –
Liver retraction
Trocars shifted
laterally
3 – Port Placement

7. LEFT RIGHT
Subcostal Subxiphoid / Subcostal
Suprapubic Low midline

8. 4 – URETERAL CATHETER

9. 5 – Renal Cooling
• Used for complex lesions with prolonged expected
warm ischemia time (>30min)
• Methods –
– Surface cooling with ice-slush
– Retrograde cold saline instillation via ureteral catheter
– Intra-arterial cold perfusion

10. • Cold ischaemia during RAPN (Ramirez et al.)*
– Feasible with good safety profile. (Ice slush)
– 13% improvement in preservation of postoperative eGFR.
– No difference at 6-month follow-up.
Ramirez D, Caputo PA, Krishnan J, Zargar H, Kaouk JH. Robot-assisted partial nephrectomy with
intracorporeal renal hypothermia using ice slush: step-by-step technique and matched
comparison with warm ischaemia. BJU Int. 2016 Mar;117(3):531–6.

11. 6 – MANNITOL
• NO evidence for mannitol use.
• Mannitol use did NOT improve short- or long-term
renal function even in patients with lower pre-
operative renal function (Wong et al)*
Wong NC, Alvim RG, Sjoberg DD, Shingarev R, Power NE, Spaliviero M, et al. Phase III Trial of
Intravenous Mannitol Versus Placebo During Nephron-sparing Surgery: Post Hoc Analysis of 3-yr
Outcomes. Eur Urol Focus. 2019 Nov;5(6):977–9.

12. • Intra-operative 12.5gm mannitol infusion during NSS
did not result in renal function improvement at 6m
(RCT by Spaliviero et al)*
Spaliviero M, Power NE, Murray KS, Sjoberg DD, Benfante NE, Bernstein ML, et al. Intravenous
Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function:
A Double-blind, Clinically-integrated, Randomized Trial. Eur Urol. 2018;73(1):53–9.

13. 7 – Method of Artery clamping
• Laparoscopic Satinsky clamp –
– Faster en-block clamping.
– Requires an additional 10-12mm port.
– Risk of inadvertent slippage.
– Not useful in retroperitoneal approach – less space.
• Bulldog clamp –
– application requires meticulous artery dissection
– Technical difficulty in manipulation – may increase WIT.

14. • Vascular Torniquet*
– Doesn’t require additional port.
– Not limited by number of vessels.
– Can be left in-situ after reperfusion for emergency re-
occlusion if needed.
Shefler A, Ghazi A, Zimmermann R, Janetschek G. Renal hilus clamping with tourniquet
during laparoscopic partial nephrectomy. BJU Int. 2011 May 1;107(10):1688–93.

15. Application of vascular
torniquet

16. 8 – Artery-Vein vs Artery-only clamp
• Recent Meta-analysis by Cao et al*
• AO clamping group had significantly lower RENAL score.
• No significant difference detected w.r.t. warm ischemia,
operating time, and estimated blood loss.
• No significant difference in early postop renal function
• Significantly better renal function (eGFR) preservation in long-
term with AO clamping group.
Cao J, Zhu S, Ye M, Liu K, Liu Z, Han W, et al. Comparison of Renal Artery vs Renal Artery-Vein
Clamping During Partial Nephrectomy: A System Review and Meta-Analysis. J Endourol. 2020
Apr;34(4):523–30.

17. • Postop decrease in regional (99m)Tc-MAG3 uptake
was significantly less in the AO group when the
ischemic time was ≥25 minutes (Funahashi et al)
Funahashi Y, Kato M, Yoshino Y, Fujita T, Sassa N, Gotoh M. Comparison of renal ischemic
damage during laparoscopic partial nephrectomy with artery-vein and artery-only clamping. J
Endourol. 2014 Mar;28(3):306–11.

18. 9 – Off-clamp Partial Nephrectomy
• Meta-analysis (Liu et al)* – Off-clamp PN had a –
• Higher blood transfusion rate
• Lower overall postoperative complication rate
• Lower positive margin rate
• Better preservation of renal function
Liu W, Li Y, Chen M, Gu L, Tong S, Lei Y, et al. Off-clamp versus complete hilar control partial
nephrectomy for renal cell carcinoma: a systematic review and meta-analysis. J Endourol. 2014
May;28(5):567–76.

19. • Meta-analysis (Antonelli et al)* –
• Off-clamp robot-assisted PN is reserved to smaller &
less complex renal masses.
• Under such conditions, no differences with the on-
clamp approach.
Antonelli A, Veccia A, Francavilla S, Bertolo R, Bove P, Hampton LJ, et al. On-clamp versus off-
clamp robotic partial nephrectomy: A systematic review and meta-analysis. Urologia. 2019
May;86(2):52–62.

20. Off-clamp techniques
• Enucleation and laser ablation of the tumor bed
• Focal radio-frequency coagulation
• Nonischemic hydrodissection
• Sharp resection with parenchymal clamping
• Preoperative superselective transarterial embolization
(P-STE)

21. • Selective arterial clamping
• Anatomical zero-ischemia MIPN - microsurgical clips
on tumor-specific tertiary or higher-order arterial
branches

22. Warm Ischemia Time
• Traditional safety limit of WIT – 30min
• Study by Dong et al* – 401 patients undergoing PN
• Each additional 10min of warm ischemia associated
with only 2.5% decline in recovery from ischemia.
Dong W, Wu J, Suk-Ouichai C, Caraballo Antonio E, Remer EM, Li J, et al. Ischemia and Functional
Recovery from Partial Nephrectomy: Refined Perspectives. Eur Urol Focus. 2018;4(4):572–8.

23. • Study by Rosen et al* –
• Extended WIT – worse perioperative outcomes with AKI &
short term decline in renal function.
• Extended WIT – Not significantly associated with renal
function decline at 1 year.
Rosen DC, Kannappan M, Paulucci DJ, et al. Reevaluating Warm Ischemia Time as a Predictor of
Renal Function Outcomes After Robotic Partial Nephrectomy. Urology. 2018;120:156‐161.
doi:10.1016/j.urology.2018.06.019

24. • Recent Meta-analysis (Greco et al)* showed that none of
the available ischemia techniques, Cold, Warm, or
Zero ischemia, is universally superior to the others.
Greco F, Autorino R, Altieri V, Campbell S, Ficarra V, Gill I, et al. Ischemia Techniques in
Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and
Functional Outcomes. Eur Urol. 2019;75(3):477–91.

25. Margin estimation without haptic feedback
• IOUS
• Image guided surgery (IGS) – three dimentional
constructed image used to guide resection.

26. • TilePro image guidance software for intra-op
tumor anatomy delineation
Hughes-Hallett, A., Pratt, P., Mayer, E., Martin, S., Darzi, A., & Vale, J. (2014). Image Guidance for
All—TilePro Display of 3-Dimensionally Reconstructed Images in Robotic Partial Nephrectomy.
Urology, 84(1), 237–243. doi:10.1016/j.urology.2014.02.051

27. IOUS
• Estimate tumor size & depth.
• Especially useful in complex tumors –
– Hilar tumors
– Predominantly Endophytic tumors
• Indications not standardized.

28. • Review article* – IOUS for NSS in patients with
technically challenging tumors
– promising oncological results – >90% negative margin rate,
comparable to exophytic tumor PN.
Rodríguez-Monsalve M, Del Pozo Jiménez G, Carballido J, Castillón Vela I. [The role of intraoperatory
ultrasound in laparoscopic partial nephrectomy for intrarenal tumors.]. Arch Esp Urol.
2019;72(8):729‐737.

29. Hilar & Completely Endophytic tumor
• Hilar Tumor – located in renal hilum in direct contact
with renal artery and/or vein.
• Central tumor – Tumor abutting or invading central
renal sinus fat and/or collecting system.
• IOUS – required to delineate tumor-parenchyma
interface.

30. • Recent systematic review* – completely endophytic
tumors – feasible with experienced surgeons
• Radio-guided occult lesion localization technique
(ROLL) facilitates localization and complete excision.
Perez-Ardavin J, Sanchez-Gonzalez JV, Martinez-Sarmiento M, et al. Surgical Treatment of
Completely Endophytic Renal Tumor: a Systematic Review. Curr Urol Rep. 2019;20(1):3.
Published 2019 Jan 16. doi:10.1007/s11934-019-0864-x

31. • Comparative study by Komninos et al*
– Increased risk of positive margins
– No increased risk of recurrence free survival
– No increased mortality
Komninos C, Shin TY, Tuliao P, et al. Robotic partial nephrectomy for completely endophytic
renal tumors: complications and functional and oncologic outcomes during a 4-year median
period of follow-up. Urology. 2014;84(6):1367‐1373. doi:10.1016/j.urology.2014.08.012

32. Posterior Tumors
• Retroperitoneal approach more favourable
• Meta-analysis – Posterior tumor location, did not
impact robotic partial nephrectomy outcomes*
Cacciamani GE, Gill T, Medina L, et al. Impact of Host Factors on Robotic Partial Nephrectomy
Outcomes: Comprehensive Systematic Review and Meta-Analysis. J Urol. 2018;200(4):716‐730.
doi:10.1016/j.juro.2018.04.079

33. • Polar Flip technique – Posterior hilar tumor
– Kidney is rotated by around 45 -60 degrees
– Lower pole faces anteriorly and upper pole posteriorly
– Increased posterior surface exposure & maneuverability
– initial flipping with dissection in Gil Vernet's plane to clip
posterior segmental renal artery
Chiruvella M, Ghouse SM, Tamhankar AS. "Polar flip" technique for transperitoneal
laparoscopic partial nephrectomy - Evolution of a novel technique for posterior hilar
tumors. Indian J Urol. 2019;35(3):230‐231. doi:10.4103/iju.IJU_235_18

34. Renorraphy over hemostatic bolster
• Achieve approximation, local compression and
hemostasis
• Multi-institutional survey (Europe and US)1: 16 out of
18 centers routinely used hemostatic bolster
[1042/1347 cases(70%)]
• SURGICEL® (Ethicon)-Oxidized Regenerated
Methylcellulose
• Spongostan®(Johnson & Johnson)porcine gelatin
absorbable sponge
Breda A, Stepanian S V, Lam J S, Liao J C, Gill I S, Colombo J R, Schulam P G. Use of
Haemostatic Agents and Glues during Laparoscopic Partial Nephrectomy: A Multi-Institutional
Survey from the United States and Europe of 1347 Cases. European Urology, 52(3), 798–803.

35. • Definitive advantage not proved by prospective study
• Parenchymal suturing with fibrin sealant and no
bolster has similar results in select(central) tumours
when PCS is not violated2
Weight, Christopher J., Brian R. Lane, and Inderbir S. Gill. Laparoscopic Partial Nephrectomy for
Selected Central Tumours: Omitting the Bolster. BJUI 100, no. 2 (August 2007): 375–78.

36. Role of hemostatic agents
• TISSEEL/TISSUCOL (Baxter Healthcare)-Fibrin glue
• FloSeal (Baxter Healthcare), SURGIFLO® (Ethicon)-
Gelatin based
• SURGICEL® (Ethicon)- Oxidized Regenerated
Methylcellulose
• BioGlue® (Cryolite)- Glutaraldehyde-based adhesive
• TachoSil® (Nycomed)-Human fibrinogen and thombin
• Vivostat® (Alleroed) - autologous, platelet-enriched,
fibrin sealant applicator

37. • No proper recommendation : lack of prospective
randomized trials
• Adjuncts to proper laparoscopic suturing – Not
substitutes
Galanakis, I, N Vasdev, and N Soomro. “A Review of Current Hemostatic Agents and Tissue Sealants
Used in Laparoscopic Partial Nephrectomy.” Reviews in Urology 13, no. 3 (2011): 131–38.

38. FIBRIN GLUE vs SUTURED BOLSTER
• Postoperative hemorrhage and urine leakage: 9% vs
2%
these cases were larger and nearer to the hilum
• Operating room time: 185 vs 210 minutes
• Blood loss : 398 vs 247 cc
• Hospital stay : 2.9 vs 2.6 days
Johnston William K., Montgomery Jeffrey S., Seifman Brian D., Hollenbeck Brent K., and Wolf J.
Stuart. “Fibrin Glue v Sutured Bolster: Lessons Learned during 100 Laparoscopic Partial
Nephrectomies.” Journal of Urology 174, no. 1 (July 1, 2005): 47–52.

39. • Closure using fibrin glue products -when the CS or
renal sinus is not entered
• When CS or renal sinus violated-sutured bolster is
recommended

40. Effect of suture material
• WIT is the strongest modifiable surgical risk factor for
postoperative chronic kidney disease
• Polyglactin 910 – Braided , resistance on tissue passage
• Polydioxonone – monofilament, stiff, difficult knotting
• Polyglecaperone- Monofilament, pliable – easy passage
and better knotting.
Riccardo B, Campi R, Klatte T, Kriegmair MC, Mir MC, Ouzaid I, Salagierski, et al. “Suture Techniques
during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative
Synthesis of Peri-Operative Outcomes.” BJU International 123, no. 6 (June 1, 2019): 923–46.

41. • Newer suture- V-LOC [Poly(glycolide-trimethylene
carbonate) copolymer]- self retaining
• Barbed suture significantly reduced warm ischemia
time.
Lin Y, Liao B, Lai S, et al. The application of barbed suture during the partial nephrectomy may
modify perioperative results: a systematic review and meta-analysis. BMC Urol. 2019 ;19(1):5.
Published 2019 Jan 10. doi:10.1186/s12894-018-0435-3

42. THANK YOU