Open Partial Nephrectomy
Open partial nephrectomy is the standard technique for organ-sparing resection of renal tumors. The minimally invasive alternative to open partial nephrectomy is laparoscopic partial nephrectomy. Review literature: ( Novick, 2002 ).
Surgical technique of open partial nephrectomy: (A) after vascular control the kidney capsule is incised (margin 5 mm) (B) The renal artery is clamped with a bulldog clamp. The tumor is resected, visible vessels may be clipped. (C) Vessels and the collecting system are closed with a running suture. The bulldog clamp is removed from the renal artery. (D) Renorrhaphy: the cortical edges are approximated with the help of interrupted sutures and clips. (E) The interrupted sutures are tied over a bolster (e.g. resorbable cellulose oder a flap of perinephric fat).
Indications for Partial Nephrectomy
Imperative partial nephrectomy:
Partial nephrectomy should always be done (if technically possible) in patients with renal cell carcinoma in a solitary kidney, if bilateral tumors are present, in chronic renal insufficiency or for patients with hereditary renal cell carcinoma.
If technically possible, the organ-preserving partial nephrectomy should be performed for every T1 tumor. Retrospective comparisons between nephrectomy and partial nephrectomy for T1 tumors showed a better prognosis for partial nephrectomy due to the reduction of cardiovascular events (Zini et al, 2009) (Weight et al, 2010). If this reduction of cardiovascular events is due to better renal function or due to selection bias is unclear, the randomized EORTC study (nephrectomy vs partial nephrectomy) did not demonstrate this effect (Van Poppel et al, 2011).
Partial nephrectomy for benign diseases:
- Caliceal diverticula
- duplex kidney with a malfunctioning (upper) portion
- hydatid cysts
Surgical Technique of Partial Nephrectomy
Preoperative patient preparation:
- Perioperative antibiotic prophylaxis is recommended
- Perioperative indwelling catheter
- Perioperative gastric tube, if a transperitoneal approach is chosen
- Consider epidural anesthesia
- Consider the placement of an ureteral stent (DJ or MJ), if a wide opening of the collecting system is planned
Open partial nephrectomy: circular incision of the renal capsule and enucleation of the tumor. Closure of the small renal defect with a running suture. With kind permission of Dr. R. Gumpinger, Klinikum Kempten.
Partial nephrectomy can be done via a transperitoneal approach (subcostal incision) or via a flank incision, depending on the location of the tumor. Most cases are managed using the retroperitoneal flank incision. The first steps of the procedure are identification and control of the ureter and renal vessels with vessel loops. The kidney is mobilized without removing the perinephric fat overlying the tumor.
Small polar tumors are resected without ischemia, manual compression of the renal parenchyma by the assistent is helpful. For larger tumors, the preparation under ischemia in a bloodless field is useful. The tolerable warm ischemia time for the kidney is controversial and depends on the author, it should not exceed 30 min. For ischemia the renal artery is selectively clamped with a bulldog clamp. Generally, the vein is not clamped since ischemic damage to the kidney should be lower with selective clamping of the renal artery. For complex partial nephrectomy, the kidney is cooled after clamping and the tolerable (cold) ischemia time is significantly longer.
The administration of an osmotic diuretic such as mannitol before (and after) clamping the renal vessels is often used to reduce reperfusion injury after renal ischemia. Protective factors of mannitol are the increase of the diuresis and antioxidant properties. The dosage is usually 25 g mannitol. Despite the widespread use of mannitol in the context of partial nephrectomy, reliable studies supporting the use of mannitol do not exist (Cosentino et al, 2012) (Power et al, 2012).
Depending on the location and size of the renal tumor various techniques are used: enucleationen, wedge excision and polar resection. In rare cases, extracorporal partial nephrectomy with autotransplantation is done. The safety distance to the tumor does not have any prognostic significance, the goal is to achieve a complete resection which is controlled by frozen sections.
The resection of the tumor without ischemia is performed with the help of an electric scalpell or ultrasonic knife. If the resection is done under ischemia, sharp and blunt dissection without coagulation allows a perfect visualization of the layers. Visible vessels are sutured (figure-of-eight stitch) or closed with clips. If the collecting system is entered, it is closed with a running suture. The preparation under ischemia should be finished within 20 min and the bulldog clamp is taken of the renal artery. The renal defect is controlled for bleeding vessels. The cortical edges are approximated with the help of interrupted sutures and clips [fig. surgical technique of partial nephrectomy]. The interrupted sutures are tied over a bolster (e.g. resorbable cellulose oder a flap of perinephric fat). Hemostyptic agents (branded as Floseal, Tachosil, Surgiflo ... ) can support hemostasis and simplify the operation.
Localized renal tumors without lymph node enlargement (T1–2 cN0) may be treated without lymphadenectomy, since the risk for lymph node metastases is very small and lymphadenectomy did not show any survival advantage in a large EORTC study (Blom et al, 1999 and 2009). Nevertheless, enlarged lymph nodes should be removed by a limited regional lymphadenectomy.
Ureteral stenting and wound drainage:
A wound drainage is always recommended. If the collecting system has been entered deeply, a DJ ureteral stent may be inserted via the opened collecting system or after suturing of the renal defect via a pyelotomy. In addition, a transurethral indwelling catheter is inserted for 5–10 days, depending on the daily volume of the drainage.
Postoperative Care after Partial Nephrectomy
- Removal of the gastric tube after surgery, clear liquid diet immediately (sips at first), advanced to regular diet as tolerated
- Early mobilization
- Intensive respiratory therapy
- Thrombosis prophylaxis
- Laboratory tests (hemoglobin, creatinine)
- Wound checks.
Analgesics according to the WHO ladder are prescribed, e.g. a combination of metamizol and tramadol. A peridural anesthesia facilitates postoperative pain management.
Complications of Partial Nephrectomy
Complications of partial nephrectomy (in comparison to radical nephrectomy) can be seen in the table complications of radical and partial nephrectomy, the data is from randomized and retrospective studies. The risk for bleeding an postoperative reinterventions are significantly increased.
Complications of radical and partial nephrectomy: (Corman et al, 2000) (Poppel et al, 2007).
|Hemorrhage <0,5 l
The risk of blood loss over 500 ml is around 13%. In the case of postoperative bleeding, radiological embolization of the bleeding is attempted. However, postoperative bleeding can rarely enforce the surgical revision which often ends with nephrectomy. A rare cause of a late bleeding complication is the formation of a false aneurysm [pseudoaneurysm after partial nephrectomy].
CT scan of a pseudoaneurysm after partial nephrectomy: the patient presented with a tamponade of the bladder 2 weeks after partial nephrectomy, the aneurysm was successfully embolized. With kind permission of Prof. Dr. K. Bohndorf, Augsburg.
Extravasation of urine:
The majority of urinomas after partial nephrectomy can managed by adequate renal drainage and placement of a ureteral catheter [urinoma after partial nephrectomy].
CT of urinoma after partial nephrectomy: the extravasation of contrast media is clearly seen in the late scans. With kind permission of Prof. Dr. K. Bohndorf, Augsburg.
Hydronephrosis may be caused by hematuria with clot formation.
Transient renal failure is caused by the ischemia of a solitary kidney, there is also a risk for terminal renal failure. The risk of hyperfiltration nephropathy increases if more than 50% of nephrons are resected. Early signs are proteinuria and rising creatinine concentrations. The treatment consists in a reduction of dietary protein and medication with ACE inhibitors.
Injury of neighboring organs:
Liver injury, splen injury (risk of splenectomy), paralytic ileus, injury of the bowel, peritonitis, injury of the pancreatic tail with fistula, pneumothorax, chylous fistula due to injury of intestinal lymphatic vessels.
Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.
Mortality due to bleeding, cardiovascular diseases, arrhythmia, acute renal failure, pulmonary embolism is around 2%.
Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
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