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Surgical Steps and Complications of Laparoscopic Partial Nephrectomy

Laparoscopic partial nephrectomy is a good option for small and exophytic growing renal tumors. Considerable technical expertise is needed to avoid a long ischemia time for renal tumors close to the hilus or larger size with infiltration of central renal structures. An acceptable warm ischemia time for the kidney varies among authors and should not exceed 30 minutes. Robotic-assisted laparoscopy enables complex partial nephrectomy, which is challenging even with open surgery.

Indications for Laparoscopic 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 kidney disease, or for patients with hereditary renal cell carcinoma.

Elective Indications:

If technically possible, a partial nephrectomy should be performed for every T1 tumor. Retrospective comparisons between nephrectomy and partial nephrectomy for T1 tumors showed a better prognosis for a 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 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:

• Calyceal diverticula
• Duplex kidney with a malfunctioning (upper) portion
• Hydatid cysts

Contraindications for Laparoscopic Partial Nephrectomy

Coagulation disorders. The other contraindications depend on the surgical risk due to the patient's comorbidity, the renal function of the contralateral kidney, and the surgical procedure's impact on the patient's life expectancy. Depending on your technical expertise, choose open partial nephrectomy for complex renal tumors.

Surgical Technique of Laparoscopic Partial Nephrectomy

Preoperative Preparations:

• To improve the intra-abdominal vision, the diet should be limited to clear liquids (water, juices, broth) on the preoperative day.
• Administer an enema the night before surgery.
• Perioperative placement of a urinary catheter and gastric tube.
• Perioperative antibiotic prophylaxis is needed if risk factors for surgical site infections are present or if the urinary tract is planned to be opened.
• Insert a transurethral catheter and gastric feeding tube during surgery.

Patient positioning:

The patient is positioned a vacuum mattress depending on the chosen approach (laparoscopy or retroperitoneoscopy), this enables a secure fixation of the patient, even if the operation table has to be tilted.

Laparoscopic approach:

The laparoscopic approach is suitable for ventral or medial renal tumors; see section laparoscopic nephrectomy for patient positioning and trocar positions.

Retroperitoneoscopic approach:

The retroperitoneoscopic approach is suitable for dorsal or lateral renal tumors; see section retroperitoneoscopic nephrectomy for patient positioning and trocar positions.

Partial nephrectomy:

Start with preparation and isolation of the renal vessels. The kidney is mobilized without removing the perinephric fat overlying the tumor. Favorably located tumors may be resected without ischemia, and good hemostasis during resection is achievable with an ultrasound scalpel. All other cases need renal ischemia to enable tumor resection in a bloodless field. Renal ischemia is possible using laparoscopic vascular clamps, bulldog clamps, or vessel loops. Depending on tumor size and location, selective hilar clamping of segmental arteries can reduce the ischemic damage to the kidney. A running suture of the defect closes opened vessels and the pyelocalyceal system. After the release of ischemia, hemostasis is optimized with bipolar coagulation and further sutures. Renal reconstruction of large defects should mimic open surgery. The safety distance to the tumor has no prognostic significance (Minervini et al., 2012). The goal is to achieve a complete macroscopic resection; a frozen section examination offers no additional safety and is only recommended in doubtful cases with sutures of clips to mark the suspicious area (Dagenais et al., 2018).

Hemostyptics (brand-name products such as Floseal, Tachosil, or Surgiflo) can support hemostasis, eliminate the need for parenchymal sutures, and simplify surgery. Administration of an osmotic diuretic such as mannitol before (and after) clamping of renal vessels is thought to decrease reperfusion injury after renal ischemia, but this has not been validated by studies, see also section open partial nephrectomy.

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., 2009). Nevertheless, enlarged lymph nodes should be removed by a limited regional lymphadenectomy.

Wound drainage:

Wound drainage of the renal fossa is always recommended.

Ureteral stenting:

Some authors prefer to insert DJ or MJ ureteral stents for deep partial nephrectomy. Ureteral stenting is possible before the surgery, via the opened collecting system, or after suturing of the renal defect via a pyelotomy. If done, a bladder catheter is inserted for 5–10 days, depending on the daily volume of the drainage.

Specimen retrieval:

Use a retrieval bag over a muscle-splitting incision of a 10 mm trocar position. Consider frozen section examination if complete resection is uncertain.

Care after Laparoscopic Partial Nephrectomy

General measures:

Early mobilization. Respiratory therapy. Thrombosis prophylaxis. Laboratory controls (Hb, creatinine). Regular physical examination of the abdomen and incision wound.

Analgesia:

Analgesics with a combination of NSAIDs and opioids.

Diet advancement:

Remove the nasogastric tube after surgery and allow small sips of clear liquids. Increase clear liquids and allow yoghurt or pudding on postoperative day 1. If the patients feels well, allow small amounts of solid food (appetite driven) starting postoperative day 2.

Drains and catheters:

For stable patients without ureteral stents, early removal of the bladder catheter within 1–2 days is possible after uneventful surgery. The wound drainage is removed if the daily drainage volume is well below 50 ml. Patients with ureteral stents need a bladder catheter until the removal of the wound drainage is possible.

Complications

In principle, the same spectrum of complications exists as in open partial nephrectomy. The laparoscopic technique reduces access-related complications like pain, surgical site infections, or hernias. Previous retrospective comparisons found a longer intraoperative ischemia time and increased intraoperative and postoperative complications compared with open surgery (Gill et al., 2003a). It remains to be seen whether improvements in laparoscopic technique and technical expertise can also reduce complications. Robotic-assisted laparoscopy is a promising tool for complex partial nephrectomy (Tang et al., 2021).

References

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.
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J. Dagenais et al., “Frozen Sections for Margins During Partial Nephrectomy Do Not Influence Recurrence Rates.,” J Endourol., vol. 32, no. 8, pp. 759–764, 2018, doi: 10.1089/end.2018.0314.

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