Treatment
Preoperative Details
Prepare patients being considered for nephron-sparing surgery (NSS) for possible radical nephrectomy. Patients should be aware of the risk for possible temporary or permanent dialysis in the setting of a solitary functioning kidney undergoing surgical intervention. The optimal treatment is often determined intraoperatively. Optimal renal perfusion provided by a hydration regimen of approximately 200 mL/h or more of crystalloids overnight often is beneficial. Alternatively, same-day admission and hydration with a 1-L crystalloid bolus over an hour prior to the scheduled operation is also used. Prepare iced slush saline for intraoperative renal cooling in anticipation of arterial occlusion and regional hypothermia.
Intraoperative Details
In most cases in which preoperative imaging is optimized and the correct incision is used, partial nephrectomy can be performed in situ. Temporary arterial occlusion and regional hypothermia are often necessary, depending on the size, location, and number of renal masses. Surgical options include enucleation with a rim of normal parenchyma, wedge resection, polar nephrectomy, or bench surgery and autotransplantation (ex vivo).
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.
Operative technique
According to the preference of the surgeon, a flank extraperitoneal or an anterior subcostal incision is used. A supine position with a tilt towards the contralateral side is the authors' preferred approach. Place a rolled towel underneath and lateral to the affected side, and slightly flex the table. Alternatively, when a flank incision is contemplated, the lateral decubitus position is used. Raise the kidney rest halfway between the iliac crest and the costal margin and flex the table. Flex the contralateral leg at the knee to provide stability and keep the ipsilateral lower extremity straight. Place pillows in between to cushion bony prominences. Wrap the outermost arm and place it on an armrest. Place an axillary roll underneath the dependent axilla to avoid brachial plexus injuries.
The authors' preferred approach, in the absence of previous abdominal surgery, is the anterior subcostal incision starting at the tip of the 12th rib, coursing 3 cm below the costal margin and extending across the midline to the opposite side when necessary.
Divide the falciform ligament after entering the peritoneum. The advantage of this incision is evaluation of the intra-abdominal viscera and excellent exposure of the renal vessels, especially in patients who are large or obese. The disadvantage is that the kidney is in the depth of the wound. The flank approach, using an extrapleural 11th or 12th rib incision, also provides excellent and rapid exposure to the kidney and the hilum and is a reasonable approach. However, in older patients or those with poor respiratory reserve, pulmonary complications are more common. This is due, in part, to increased pain associated with this incision compromising deep inspiration and subsequently leading to more atelectasis.
Optimal renal exposure is the key to a successful outcome. Mobilize the abdominal viscera accordingly and identify the kidney. Identify the renal pedicle and define the vasculature. Then, isolate the renal artery and place a vascular loop. Avoid excessive dissection and leave surrounding perivascular adventitial layers intact to serve as a cushion if application of a vascular clamp is contemplated. This reduces the risk of intimal damage to the artery, which can result in arterial thrombosis. Except for the fat directly overlying the tumor, dissect the perirenal fat free. Enucleation with a rim of normal parenchyma can be used for smaller lesions (<3 cm) (see Image 1). Usually, renal occlusion is not necessary.
Score the capsule with electrocautery. A plane is usually identified outside the pseudocapsule of the tumor and developed with the butt end of a scalpel handle or small Metzenbaum scissors. Then, excise the tumor with a combination of blunt and sharp dissection. While the assisting surgeon applies intermittent pressure, suture-ligate any bleeding vessel with 5-0 absorbable sutures.
Send a frozen section from the tumor crater bed, which represents the deep margin, to the laboratory. The crater is inspected for evidence of entry into the collecting system. If in doubt, 5 mL of indigo-carmine can be administered intravenously or intrapelvically (collecting system), and the tumor bed can be inspected for any leaks. Use thrombin-soaked Surgicel liberally to aid in hemostasis. When the defect is small, approximate the renal capsule to cover the defect with Gelfoam or Surgicel bolsters. If the defect is relatively large, close the parenchymal defect with exogenous Gore-Tex bolsters.
Larger lesions require temporary arterial occlusion and hypothermia. Preoperative definition of the renal vasculature is more imperative if a larger partial resection is contemplated. When in doubt, the appropriate segmental artery that supplies the tumor can be identified by injection of indigo-carmine (see Image 2). Leave the areolar tissue intact at the junction of the renal vein and the vena cava to provide increased stability of the renal vein. Initiate diuresis with intravenous mannitol and a loop diuretic (eg, furosemide) intraoperatively, with generous hydration before any interruption in the renal circulation. Infuse mannitol (12.5 g) intravenously 5 and 10 minutes before anticipated renal occlusion. This agent not only induces osmotic diuresis but also is a free-radical scavenger that can minimize ischemic insult from arterial clamping and the ultimate risk of postoperative acute tubular necrosis.
Then, occlude the renal artery with an atraumatic vascular bulldog and wrap a plastic sheet around the kidney. The authors do not routinely occlude the renal vein because retrograde perfusion of the kidney might minimize the chance for postoperative acute tubular necrosis. It also allows for easier identification of renal veins for ligature in the parenchyma and differentiation from small tangential cuts in the collecting system at the time of resection.
Maintain liberal hydration throughout the procedure. Apply iced saline slush and cool the kidney to allow for adequate core renal hypothermia (see Image 3). Then, resect the renal mass with a combination of blunt and sharp dissections with a 1- to 2-cm margin of normal renal parenchyma (see Image 4). Send frozen sections from the crater of the tumor bed to the laboratory. After the lesion is removed, suture-ligate the bleeding arteries and the visible bleeding veins with 4-0 absorbable sutures. Close the collecting system, if entered, with a 5-0 absorbable suture (see Image 5). If the collecting system is not easily identified, indigo-carmine can be injected into the renal pelvis to detect an obvious leak while the ureter is occluded.
With the assistant approximating the edges of the parenchymal defect (see Image 5), close the defect over a Surgicel/Gelfoam roll to aid in parenchymal pressure and hemostasis. Two strips of Gelfoam wrapped in Surgicel can be used to bolster the renal capsule along the edges of the defect to reduce the risk of tearing. Lay the 2 strips along the length of the defect on each side. Pass several 2-0 polyglycolic acid horizontal mattress sutures through the renal capsule, approximately 1 cm away from the edge of the parenchymal defect on each side, thereby incorporating the Gelfoam/Surgicel strips along each side of the defect (see Image 6).
The parenchyma is malleable owing to arterial occlusion and should be closed along whichever axis allows for an easier approximation. Then, tie the interrupted sutures over the bolster. Place all sutures first. Have the assistant provide uniform and direct approximation while tying these sutures. Then, remove the arterial clamp and perfuse the kidney.
Large polar resections are approached in the same manner and are invariably performed best under regional hypothermia and arterial occlusion with core cooling. Usually, a transverse resection is required (see Image 7). These are usually larger lesions and require ligation of the segmental arteries and veins that supply the tumor and the corresponding section of the kidney. Carefully note the position of the ureter and the renal pelvis and close the collecting system with a running 5-0 absorbable suture. Because of the usually extensive resection, insertion of an indwelling double-J ureteral stent, placed antegrade intraoperatively or cystoscopically prior to open surgery, is advisable. Close the parenchymal defect as described above.
Most partial nephrectomies are amenable to in situ techniques. With adequate cooling and exposure, 3 hours of safe ischemia is ample time for resection of almost all renal tumors. In the past, an indication for ex vivo (ie, bench) NSS was a centrally located tumor with concerns of adequate tumor excision and reconstruction. A recent study from a single center with extensive experience in NSS did not find the location of the tumor (central vs peripheral) to be a significant factor affecting outcome, especially in single, small, unilateral, and incidentally detected RCC.
Today, in experienced hands, bench surgery is usually not necessary. The most perceivable indication is the presence of a large central tumor in a solitary kidney. The technique involves a standard radical nephrectomy with particular attention to preserving the maximum length on the renal artery and vein. Administer intravenous mannitol (total 25 g) 5 and 10 minutes before removal and achieve maximum ureteral length with adequate adventitia.
Provide adequate hydration and administer furosemide liberally to maintain diuresis. After removal, perfuse the kidney with University of Wisconsin solution or Euro-Collin solution at 70°C via the renal artery and place the kidney in a shallow basin filled with cold saline slush. Resect the tumor. The frozen section analysis of the margins is obtained. Then, perform the reconstruction as described above. Infusion of the artery and vein with Euro-Collin solution before transplantation allows for identification and closure of small leaking vessels. Reimplant the reconstructed kidney in the contralateral iliac fossa with the standard renal transplantation technique (see Image 8). Stent and reimplant the ureter with a modified Lich-Gregoire technique.
Postoperative Details
With adequate preoperative planning, meticulous surgical technique, proper patient selection, and attention to detail, NSS can be performed with minimal morbidity and excellent outcomes for most patients selected. The role of partial nephrectomy in the setting of metastatic disease and a solitary kidney is not clearly defined. Certainly, this operation is contraindicated in the presence of nodal metastases. The use of intraoperative adjuncts such as ultrasonography and, especially, frozen section analysis is invaluable to the operating surgeon for prompt and effective decision making. The placement of a closed suction drain is essential after NSS.
Use of the described techniques provides a watertight closure of large parenchymal defects. Certainly, other traditional methods of closure (eg, closure of the parenchyma with horizontal sutures over the length of the defect with fat or Oxycel or closure with Gelfoam and Surgicel bolsters) have been successfully used. These methods depend on the strength of the renal capsule. Use of Gore-Tex allows for even distribution of tension along the length of the closure. Small bleeding vessels are easily tamponaded. Gore-Tex also allows the surgeon to tie the sutures with the desired tension without risking tear of the kidney capsule, especially when the arterial clamp is removed in transverse resections carried out for larger tumors.
One concern about the use of exogenous material has been postoperative tissue reaction that might occur, particularly when a repeat resection is contemplated in the future. In the authors' experience, Gore-Tex is relatively unreactive, and, although a pseudocapsule forms, the subsequent explorations have not been difficult and the inflammatory tissue reaction around the Gore-Tex has been minimal.
Follow-up
After NSS, patients are advised to return in 4-6 weeks for serum creatinine measurement and intravenous pyelography. In the absence of obstruction, the patient should undergo CT scanning every 6 months for 2 years and then yearly for the next 5 years, after which, the frequency is decreased to every 2 years. Chest radiography and measurements of serum calcium, alkaline phosphatase, liver function tests, and creatinine are obtained yearly for the initial 5 years and biannually thereafter. Some advocate the frequency of postoperative evaluation as dictated by the initial tumor stage, with less rigorous structured follow-up for low-stage, small tumors.
Complications
Most complications of nephron-sparing surgery (NSS) can be managed conservatively. However, the risk of a significant complication increases with the technical complexity of the case. Direct correlation exists between morbidity and the extent of NSS. The least morbidity occurs in enucleation and in situ conservative surgery, in which most tumors are smaller and peripherally located. In these patients, the morbidities of NSS parallel those of radical nephrectomy.
Accordingly, complication rates are higher in larger tumor resections in patients who have multifocal or bilateral tumors or in resections in patients with large tumors in a solitary kidney. Extracorporeal surgery is associated with increased risk of major complications, including renal vascular thrombosis and renal failure. These resections usually involve extensive manipulation of the renal vasculature and collecting system.
Hemorrhage
The most troublesome and common intraoperative complication of partial nephrectomy is excessive bleeding. In this respect, meticulous dissection, attention to detail, and ligation of intraparenchymal vessels are of paramount importance. Easy access to the renal hilum, provided by early identification and isolation of the renal artery, provides the additional safety of prompt arterial occlusion when excessive bleeding precludes a clear surgical field and adequate visualization. Postoperative hemorrhage is usually self-resolving and may be confined to the retroperitoneum or may be present with gross hematuria, decreased hematocrit, or flank ecchymosis. Treatment is expectant, consisting of volume resuscitation, serial hematocrits, and bedrest. Embolization is an option in the unusual case in which bleeding persists after conservative management and requires multiple transfusions. Reexploration is the last resort for severe intractable bleeding.
Urinary fistula
Recognized entry into the collecting system intraoperatively requires surgical repair. Failure to do so can result in postoperative urinoma. Risk factors include central location, larger tumor size, and increased complexity of the nephron-sparing operation. A small amount of urinary leakage is conceivably common and usually ceases spontaneously. Persistent drainage through the drain suggests a larger leak, which can still be managed expectantly. In the absence of ureteral obstruction, most leaks seal as more tissue healing occurs. If a urinoma forms after the flank drain has been removed, placement of a percutaneous drainage catheter in the urinoma is indicated to prevent abscess formation. Also, draining the collecting system with a percutaneous nephrostomy tube or, preferably, with a ureteral stent to seal the leakage site in the collecting system, is often helpful.
Renal insufficiency
Most cases of renal insufficiency after NSS are the result of transient ischemia during surgery and usually resolve spontaneously. Attention to intraoperative measures to decrease the possibility of this complication, namely hydrating preoperatively, correcting electrolyte abnormalities, using mannitol, maintaining minimum arterial clamp time, and using surface hypothermia, is preventive.
Patients should be aware of the risk of postoperative acute tubular necrosis and the possibility of temporary or permanent dialysis, especially in the setting of a solitary kidney. When recognized postoperatively, appropriate fluid and electrolyte management and use of dialysis (if necessary) can aid in the return of renal function. Stop nephrotoxic medications or alter the dosages. In one series, only 6.5% of patients progressed to end-stage renal disease requiring renal replacement therapy at an average of 8.2 years, of whom 5 had preoperative renal dysfunction.4
Lau et al from the Mayo Clinic have addressed the risk of chronic renal failure after partial nephrectomy versus radical nephrectomy with a normal contralateral kidney (unpublished data). This long-term series included 328 patients who were optimally matched for year of surgery, age, sex, renal function, and grade, stage, and size of tumor. The 10-year and 15-year local recurrence-free survival rates were 95% and 99% for partial and radical nephrectomy patients, respectively. Tumor in the contralateral kidney occurred in 1% of the patients in each group. The 10-year and 15-year cause-specific survival rates were 98% and 91%, respectively, for partial nephrectomy and 96% (10 y and 15 y) for radical nephrectomy; thus, no difference in outcome was observed.
More recently, Huang et al (2006) from the Memorial Sloan Kettering cancer center have suggested that radical nephrectomy places the patient in the realm equivalent to that of chronic kidney disease.5 In this retrospective study, 662 patients with normal renal function and 2 healthy kidneys underwent elective partial or radical nephrectomy for a solitary tumor that was 4 cm or smaller. The glomerular filtration rate (GFR) was estimated using the abbreviated Modification in Diet and Renal Disease Study equation. Twenty-six percent of patients had renal failure prior to the operation.
Postoperatively, the 3-year probability that the patient would be free from a newly onset GFR of lower than 60 mL/min per 1.73 m2 was 80% (95% CI, 73-85) after partial nephrectomy and 35% (28-43; P <0.001) after radical nephrectomy; corresponding values for a GFR of lower than 45 mL/min per 1.73 m2 were 95% (91-98) and 64% (56-70; P <0.001), respectively.
Multivariable analysis showed that undergoing radical nephrectomy remained an independent risk factor for a newly onset GFR of lower than 60 mL/min per 1.73 m2 (hazard ratio, 3.82 [95% CI, 2.75-5.32]) and 45 mL/min per 1.73 m2 (11.8 [6.24-22.4]; both P <0.001). They concluded that undergoing radical nephrectomy is a significant risk factor for the development of chronic kidney disease and may no longer be regarded as the criterion standard treatment for small renal cortical tumors.
Renal replacement therapy (ie, hemodialysis) was required more often in the nephrectomy series than in the NSS group. Furthermore, patients in the radical nephrectomy group had significantly higher serum creatinine levels (P = .003; 1.6 mg% vs 1.3 mg%) than in the nephron-preserving group. This series is particularly credible because of its long-term follow-up (15 y), and it presents compelling evidence that partial nephrectomy is associated with significantly less renal failure than ipsilateral radical nephrectomy in the presence of a contralateral normal kidney.
Other complications
Other complications can include infections or those attributable to anesthesia (eg, atelectasis and pneumonia). Appropriate antibiotic treatment and postoperative use of incentive spirometry can help to decrease incidence and to aid in management.
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References
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Keywords
nephron-sparing surgery, NSS, RCC, renal cell carcinoma, renal parenchymal-sparing surgery, partial nephrectomy, radical nephrectomy, synchronous bilateral tumors, tumors in a solitary kidney, poorly functional contralateral renal unit, renal lesions, renal tumors, renal oncocytoma, renal angiomyolipoma, renal multilocular cyst, renal-preserving surgery, nephron-preserving surgery, hereditary papillary renal cell carcinoma, hereditary papillary RCC, von Hippel-Lindau syndrome, VHL syndrome, cystic renal neoplasm, solid renal neoplasm
