|Year : 2017 | Volume
| Issue : 2 | Page : 110-113
Partial nephrectomy for renal cell carcinoma: Operative steps
Rajendra B Nerli1, Ranjeet Patil1, Prasad Magdum1, Vikas Sharma1, Shridhar Ghagane2
1 Department of Urology, KLES Kidney Foundation, KLE University's, JN Medical College, Belagavi, Karnataka, India
2 Department of Urology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
|Date of Web Publication||11-Oct-2017|
Rajendra B Nerli
Department of Urology, KLE University's, JN Medical College, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Open partial nephrectomy (PN) is the standard technique for organ-sparing resection of renal tumors. PN traditionally was 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. Today, indications for PN have considerably widened to include most renal masses that can be safely and completely removed independent of their size.
Keywords: Partial nephrectomy, renal cell carcinoma, kidney sparing, operative steps
|How to cite this article:|
Nerli RB, Patil R, Magdum P, Sharma V, Ghagane S. Partial nephrectomy for renal cell carcinoma: Operative steps. J Sci Soc 2017;44:110-3
| Introduction|| |
Historically, partial nephrectomy (PN) was performed under restricted, essential conditions for patients with a tumor in a solitary kidney, bilateral kidney tumors, or for patients with chronic renal insufficiency due to intrinsic renal dysfunction or calculus disease. Due to the increased use of cross-sectional imaging for nonspecific musculoskeletal or abdominal complaints or during unrelated cancer care, approximately 70% of renal tumors are now detected incidentally at a small size (<4 cm). Although the traditional radical nephrectomy (RN) was liberally used to resect these small tumors in patients with a normal contralateral kidney, the realization that at least 20% of these tumors were benign and 25% were indolent coupled with equivalent oncological outcomes whether RN or PN was performed, lead to the current era of kidney-sparing or nephron-sparing surgery. Recent data associating RN with the development of chronic kidney disease (CKD), cardiovascular morbidity, and worse overall survival when compared to PN have led to the recommendation by the 2009 American Urological Association Guidelines Committee that PN should be performed whenever technically feasible for the management of the T1 renal mass.
| Case Report|| |
A 42-year-old male presented to the uro-oncological services of the hospital with vague abdominal complaints. Abdominal ultrasonography revealed a left-sided renal mass lesion. Computed tomography (CT) scan confirmed a left-sided mid-polar mass of about 5 cm in diameter [Figure 1]a and [Figure 1]b. A clinical diagnosis of renal cell carcinoma was made, and the patient was posted for partial cystectomy. PN was done under general anesthesia.
|Figure 1: (a and b) Computed tomography scan shows a left-sided mid-polar mass of the size 5 cm × 5 cm|
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Preoperative assessment and surgical planning
Medical comorbidities especially affecting the cardiovascular system and kidney were investigated in detail. History of heavy cigarette smoking, hypertension, diabetes, and coronary artery disease was noted in detail, and a detail physical examination was performed preoperatively. These factors are known to contribute to perioperative complications and may also be etiological factors in the development of kidney cancer. Cardiac status was evaluated by performing echocardiogram, stress test, and carotid duplex studies. In addition, estimated glomerular filtration rate was calculated as it is well known that approximately 26% of patients undergoing PN have CKD which they were unaware of.
A careful evaluation of all imaging pictures was done. It is very important to note that a renal mass should not be operated without a noncontrast CT image to rule out the possibility of detecting macroscopic fat indicative of angiomyolipoma  and a contrast-enhanced study (magnetic resonance imaging, CT, or renal perfusion/excretion scan) indicating bilateral renal function. “Renal protocol” CT imaging, consists of 3 imaging sequences including precontrast, corticomedullary phase, and late nephrogenic excretory phase, provides a high degree of diagnostic accuracy in diagnosing renal cortical tumors (100% specificity, 95% sensitivity) but cannot determine if the mass is benign or malignant. Ultrasound can fully characterize cystic lesions and serves as an effective template for intraoperative ultrasound which can be highly effective in locating small subcortical renal tumors.
Technique of open partial nephrectomy
An effective flank incision is the supra-11th rib “mini-flank” retroperitoneal approach which provides rapid and excellent exposure to the kidney without the need for a rib resection. With the patient in the standard flank position [Figure 2], a 8–10 cm extraperitoneal incision is performed between the bed of the 10th and 11th ribs. The latissimus dorsi, external oblique, and internal oblique muscles are transected, and the transversus abdominis is divided in the direction of its fibers while preserving the intercostal neurovascular bundle. Using blunt dissection, the peritoneal cavity is mobilized medially, the perinpehric soft tissues laterally, and the diaphragmatic fibers and pleural superiorly. A small incision in the plane between the soft tissues overlying the psoas muscle and Gerota's fascia is then bluntly developed exposing the kidney, ureter, and ipsilateral great vessel (vena cava, aorta). The Bookwalter retractor (Codman and Shurtleff, Inc., Raynham, MA, USA) is placed using the bladder blade attachment to retract the 10th rib and rib cage superiorly, while the short right angle blade retracts the 11th rib inferiorly. A malleable blade retracts the peritoneal cavity and its intestinal contents medially. Careful dissection is conducted to isolate the ureter, renal artery, and renal vein, each of which is surrounded by a different colored vessel loop. On the left side, division of the gonadal vein and adrenal vein liberate the renal vein more fully, facilitate identification and isolation of the renal artery, and allow for substantial upward mobilization of the renal hilum and easy access to the entire kidney. Dense lymphatic vessels that commonly surround the renal artery are ligated and divided further facilitating upward mobilization of the kidney which allows a decrease in venous bleeding during the tumor resection and allows easy identification and repairs of rents in renal sinus veins. After the renal hilum has been fully dissected, the upper pole of the kidney is separated from the adrenal using blunt dissection between the two, and perforating vessels and soft tissues are ligated and divided. With the kidney completely mobilized, careful palpation and inspection of its entire surface are performed to confirm the presence of the tumor and seek any satellite lesions.
All preoperative imaging is available in the operating room, and intraoperative ultrasound is routinely utilized to confirm the presence of the tumor, seek satellite lesions, and assess the proximity of the tumor to intrarenal veins and to determine if there is an intrarenal vein thrombus or tumor encroachment upon the renal collecting system. Occasionally, a polar segmental artery may feed the exact tumor-bearing area of the kidney. Ligation and division of this artery allow for a “regional ischemia” and precise resection with little damage to nontumor-bearing kidney. When there is a completely intrarenal tumor without any evidence on the renal cortical surface, measurements from each pole of the involved kidney in millimeters are made using the preoperative CT scan with subsequent corresponding marks made on the renal cortex; the position of the endophytic tumor is then confirmed precisely with the intraoperative ultrasound. For a purely exophytic tumor or in a patient with significant underlying CKD, resection of the tumor without renal artery occlusion is carried out. For other patients with large, endophytic, or perihilar tumors who require renal artery occlusion, renoprotective measures including mannitol infusion (12.5 g/200 ml of normal saline) and ice slush are routinely used. It is no longer necessary to place the kidney in a plastic bag before ice slush placement since the small surgical mini-flank incision does not lead to patient hypothermia. In no cases of open PN is renal artery occlusion used without such renoprotective measures recommended (warm ischemia).
Once the tumor is isolated with its surrounding perinephric fat, the renal cortex is scored with a 1 cm margin using the electrocautery [Figure 3]. Sharp scissor dissection is utilized with a careful eye to keep the plane of surgical dissection within the renal cortex (pink kidney tissue) and not get too close to the renal tumor and its pseudocapsule. If dissection is too close, readjustment to a deeper plane of dissection is made. Once the renal sinus is entered beneath the tumor, 3–0 absorbable sutures are used to close any open small veins and arteries or breaches in the collecting system both to secure these structures and provide upward traction on the kidney. A later search for venous bleeding can be accomplished by simply dropping the kidney into the wound and then raising it again.
|Figure 3: A 5 mm margin created around the exophytic tumor and the tumor excised with sharp dissection|
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Once the specimen is delivered, it is carefully inspected to be certain that the lesion is intact and that there is a complete covering layer of kidney and soft tissue. The deep tumor surgical margin is marked with a silk suture to orient the specimen which is then delivered to the pathology department fresh and in sterile condition. Frozen section of the deep margin and specimen can provide immediate reassurance to the surgeon and family, but a final pathological diagnosis of the renal cortical tumor may not be available by frozen section due to the need to perform immunohistochemical or cytogenetic analysis. With the aid of ×2.5 loupe magnification, defects in collecting system and small vessels are easily identified and closed/ligated using 3–0 or 4–0 absorbable suture with special care taken to separately repair veins and arteries and avoid large bulky deep bites into the renal sinus which could cause an iatrogenic arteriovenous fistula or pseudoaneurysm.
Endophytic tumors can emanate from elements of the renal cortex facing the renal sinus and be impalpable. Intraoperative ultrasound is essential to precisely locate the tumor and plan the nephrectomy incision. Cold ischemia with ice slush is utilized. Access to the renal sinus is achieved by going through the cortex preferably in avascular plane (Brodel's line) whereupon the renal tumor is palpated and carefully resected with care being taken not to get too close to the tumor or enter its pseudocapsule. Following ligation of all renal sinus vessels and collecting system repair, the argon beam coagulator [Figure 4] is used on the parenchymal surface and perinephric fat, and hemostatic agents such as FloSeal (Baxter, Deerfield, IL, USA) and Surgical packing (Johnson and Johnson, New Brunswick, NJ, USA) are then placed in the resection cavity. Zero chromic blunt-tipped liver sutures are then placed between pledgets of surgicel to reapproximate the edges of renal cortex and close the resection cavity [Figure 5]. The renal artery is unclamped, and gentle pressure over the entire kidney is utilized for 3–5 min. If no bleeding is observed and the collecting system was entered, a closed suction is placed through a separate stab wound in the retroperitoneal space in a dependent position posterior to the kidney. For exophytic tumors excised [Figure 6] completely without entry into collecting system, the drain can safely be omitted. If oozing from the resection bed persists, another 5 min period of gentle compression is applied. If brisk arterial bleeding is observed, inspection of the surgicel bed and ligation of the bleeder is performed. Reclamping of the renal artery is avoided to prevent reperfusion injury to the kidney. The surgicel incision is closed in 2 layers using # 1 polydioxanone, and the skin incision is reapproximated using 4–0 absorbable sutures in a subcuticular fashion.
|Figure 4: Following excision of the tumor, the bed is sprayed with argon beam coagulator|
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Postoperatively, the patient had an uneventful recovery. Histopathological examination of the tumor features of clear cell carcinoma, with areas of hemorrhage and necrosis amidst the neoplastic cells. The renal capsule and compressed renal tissue beyond the neoplasm showed no invasion.
| Discussion|| |
When technically feasible, PN is the preferred method of choice for managing most renal masses to preserve maximum renal function. While in the past, PN was reserved for specific conditions (bilateral tumors, tumor in a solitary kidney, patient at high risk of future renal failure) and small tumors <4 cm in diameter; indications for PN have considerably widened to include most renal masses that can be safely and completely removed independent of their size.,
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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