Dr. med. Dirk Manski



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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).
figure open partial nephrectomy surgical technique

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.

Elective Indications:

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:

Contraindications

Coagulation disorders.

Surgical Technique of Partial Nephrectomy

Preoperative patient preparation:



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.

figure open partial nephrectomy enucleation


Surgical approach:

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.

Renal ischemia:

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).

Tumor excision:

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.

Lymphadenectomy :

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

General measures:

Analgesia:

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).
Complication Radical nephrectomy Partial nephrectomy
Significant hemorrhage 1,1 % 3,4 %
Hemorrhage <0,5 l 96 % 87 %
Urinoma 0 % 4 %
Reintervention 2,4 % 4,4 %
Mortality 2 % 1,6 %

Bleeding risk:

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].


figure CT scan of false aneurysm 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].

 figure CT of 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:

Hydronephrosis may be caused by hematuria with clot formation.

Renal failure:

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.

General complications:

Wound infection, heart attack, stroke, heart failure, thrombosis, pulmonary embolism, atelectasis, pneumonia, acute renal failure.

Mortality:

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





References

Blom u.a. 1999 BLOM, J. H. ; POPPEL, H. van ; MARECHAL, J. M. ; JACQMIN, D. ; SYLVESTER, R. ; SCHRODER, F. H. ; PRIJCK, L. de:
Radical nephrectomy with and without lymph node dissection: preliminary results of the EORTC randomized phase III protocol 30881. EORTC Genitourinary Group.
In: Eur Urol
36 (1999), Nr. 6, S. 570–5

Blom, Jan H M; van Poppel, Hein; Maréchal, Jean M; Jacqmin, Didier; Schröder, Fritz H; de Prijck, Linda; Sylvester, Richard & E. O. R. T. C. Genitourinary Tract Cancer Group
Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881.
Eur Urol, 2009, 55, 28-34.

Corman u.a. 2000 CORMAN, J. M. ; PENSON, D. F. ; HUR, K. ; KHURI, S. F. ; DALEY, J. ; HENDERSON, W. ; KRIEGER, J. N.:
Comparison of complications after radical and partial nephrectomy: results from the National Veterans Administration Surgical Quality Improvement Program.
In: BJU Int
86 (2000), Nov, Nr. 7, S. 782–789

Cosentino, M.; Breda, A.; Sanguedolce, F.; Landman, J.; Stolzenburg, J.; Verze, P.; Rassweiler, J.; Poppel, H. V.; Klingler, H. C.; Janetschek, G.; Celia, A.; Kim, F. J.; Thalmann, G.; Nagele, U.; Mogorovich, A.; Bolenz, C.; Knoll, T.; Porpiglia, F.; Alvarez-Maestro, M.; Francesca, F.; Deho, F.; Eggener, S.; Abbou, C.; Meng, M. V.; Aron, M.; Laguna, P.; Mladenov, D.; D'Addessi, A.; Bove, P.; Schiavina, R.; Cobelli, O. D.; Merseburger, A. S.; Dalpiaz, O.; D'Ancona, F. C. H.; Polascik, T. J.; Muschter, R.; Leppert, T. J. & Villavicencio, H.
The use of mannitol in partial and live donor nephrectomy: an international survey.
World J Urol, 2012.

Novick 2002 NOVICK, A. C.:
Nephron-sparing surgery for renal cell carcinoma.
In: Annu Rev Med
53 (2002), S. 393–407

Poppel u.a. 2007 POPPEL, Hendrik V. ; POZZO, Luigi D. ; ALBRECHT, Walter ; MATVEEV, Vsevolod ; BONO, Aldo ; BORKOWSKI, Andrzej ; MARECHAL, Jean-Marie ; KLOTZ, Laurence ; SKINNER, Eila ; KEANE, Thomas ; CLAESSENS, Ilse ; SYLVESTER, Richard ; RESEARCH for the European Organization for ; CANCER (EORTC), Treatment of ; CANADA CLINICAL TRIALS GROUP (NCIC CTG), National Cancer I. of ; (SWOG), Southwest Oncology G. ; EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) the:
A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.
In: Eur Urol
51 (2007), Jun, Nr. 6, S. 1606–1615

Poppel, H. V.; Pozzo, L. D.; Albrecht, W.; Matveev, V.; Bono, A.; Borkowski, A.; Colombel, M.; Klotz, L.; Skinner, E.; Keane, T.; Marreaud, S.; Collette, S. & Sylvester, R.
A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.
Eur Urol, 2011, 59, 543-552.


Power, N. E.; Maschino, A. C.; Savage, C.; Silberstein, J. L.; Thorner, D.; Tarin, T.; Wong, A.; Touijer, K. A.; Russo, P. & Coleman, J. A.
Intraoperative mannitol use does not improve long-term renal function outcomes after minimally invasive partial nephrectomy.
Urology, 2012, 79, 821-825.


Weight, C. J.; Larson, B. T.; Fergany, A. F.; Gao, T.; Lane, B. R.; Campbell, S. C.; Kaouk, J. H.; Klein, E. A. & Novick, A. C.
Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses.
J Urol, 2010, 183, 1317-1323

Zini, L.; Perrotte, P.; Capitanio, U.; Jeldres, C.; Shariat, S. F.; Antebi, E.; Saad, F.; Patard, J.; Montorsi, F. & Karakiewicz, P. I.
Radical versus partial nephrectomy: effect on overall and noncancer mortality.
Cancer, 2009, 115, 1465-1471


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