Laparoscopic partial nephrectomy and minimally invasive nephronsparing surgery

Surgical extirpation remains the most effective therapy for renal cell carcinoma. The surgical management of renal masses has evolved away from radical nephrectomy and now includes nephron-sparing surgery for small tumors. Nephron-sparing surgery has similar cure rates and does not appear to compromise cancer control. As the detection of small renal masses by widespread abdominal imaging continues to increase, so will the demand for minimally invasive nephron-sparing procedures. Despite progress in surgical techniques, laparoscopic partial nephrectomy remains a technically challenging procedure. In this review, we discuss the challenges and recent advances in laparoscopic partial nephrectomy and other minimally invasive approaches to renal masses.     

Minimally invasive radical nephrectomy: a contemporary review

Minimally invasive renal surgery has revolutionized the surgical management of renal cancer since the initial report of laparoscopic nephrectomy in 1991. Laparoscopic nephrectomy became the mainstay of management in surgically resectable renal masses since the 1990s. The growing body of literature supporting nephron-sparing surgery over the last two decades has meant that minimally invasive radical nephrectomy (MI-RN) is now the preferred treatment for renal tumors not amenable to partial nephrectomy. While there is a well-described experience with complex radical nephrectomy using standard laparoscopy, robot-assisted surgery has shortened the learning curve and facilitated greater uptake of minimally invasive surgery in difficult surgical scenarios traditionally performed open surgically. Increased experience and expertise with robot-assisted renal surgery has led to expansion of the indications for MI-RN to include larger masses, locally advanced renal masses invading adjacent tissues or regional hilar/retroperitoneal lymph nodes, cytoreductive nephrectomy (CN) in metastatic disease, and concurrent venous tumor thrombectomy for renal vein or inferior vena cava (IVC) involvement. In this article, we review the various surgical techniques and adjunctive procedures associated with MI-RN.     

The Role of Minimally Invasive Surgery in Multifocal Renal Cell Carcinoma

Surgical excision remains the reference standard for treatment of localized renal cell carcinoma (RCC). Laparoscopic and robotic minimally invasive extirpative approaches are being increasingly employed in current urologic practice. Multiple tumors in the same kidney present a unique set of challenges for minimally invasive surgeons. As such, we review recent literature regarding minimally invasive nephron-sparing surgery in patients with synchronous, ipsilateral, multifocal renal tumors. As the experience with these complex operations grows, perioperative, short-term functional and oncologic outcomes appear comparable to traditional open nephron-sparing surgery. Data on surgical approaches to patients with synchronous, ipsilateral, multifocal RCC are emerging. Short-term results suggest minimally invasive nephron-sparing surgery is safe, feasible, and should be considered as a potential treatment option for patients who present with multiple tumors in the same renal unit.     

Ablative techniques for the management of kidney cancer

For lesions smaller than 4 cm, nephron-sparing surgery has been shown to be oncologically equivalent to radical nephrectomy, albeit with the advantage of preservation of overall renal function. As such, partial nephrectomy became the first-line treatment option for localized, small renal masses. Minimally invasive options associated with limited morbidity--such as probe-ablative procedures--are, however, being investigated in selected patients for whom invasive, nephron-sparing surgery (whether laparoscopic or open) is undesirable. The main probe-ablative techniques being investigated as alternatives to partial nephrectomy are cryoablation, radiofrequency ablation, and high-intensity focused ultrasound. Advances in imaging, ablative system technologies, and early evidence that in situ tumor ablation can yield comparable results to those achieved with tumor resection in selected cases, have sparked significant interest in these minimally invasive techniques.     

Partielle Nephrektomie – pro robotisch assistierte laparoskopische Operation

An ever increasing use of imaging in medicine during recent years has resulted in accidental detection of an increasing number of asymptomatic small renal masses. To prevent secondary cardiovascular morbidity through loss of renal function, nephron-sparing surgery is performed for most of these masses. Minimally invasive surgery is a way to prevent postoperative complications, such aspneumonia and pain by avoiding wide incisions and by earlier mobilization of the patient. Since 2004 robotic-assisted laparoscopic nephron-sparing surgery has become a feasible alternative. It shows good functional results, less blood loss and shorter warm ischemia time compared to conventional laparoscopy. The complications can be assigned to Clavien scale grades I and II and can be treated conservatively in most cases. New surgical techniques reduce the number of tumors that cannot be operated on robotically because of size and location of the tumor. Robotic-assisted laparoscopic nephron-sparing surgery is a safe and useful alternative to conventional laparoscopy and open surgery for small renal masses.     

Surgical Treatment of Localised Renal Cancer

The management of localised renal cancer has been revolutionised with the introduction of laparoscopy and minimally invasive techniques, achieving comparable oncologic results and reduced morbidity. With the detection rate of small renal lesions increasing, the diagnostic approach and surgical treatment shift to nephron-sparing surgery and less invasive techniques.Today, open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), radiofrequency ablation, and cryotherapy are treatment options. Comparing OPN and LPN, multicentre studies have shown equivalent cancer-specific survival rates. Robot-assisted partial nephrectomy seems to have an advantage with regard to decreased ischemia time compared to conventional laparoscopy.OPN and LPN are now preferred treatment options for the surgical treatment of smaller renal lesions (<7 cm). With increasing experience in minimally invasive techniques, the laparoscopic and robotic approaches are becoming the preferred techniques in specialised centres. Promising novel augmented reality tracking systems may further improve the surgical and oncologic outcome of laparoscopic and robotic procedures.     

Hand-assisted laparoscopic partial nephrectomy

The resurgence of nephron-sparing surgery for selected renal masses has fueled interest in minimally invasive approaches. Several authors have shown that laparoscopic partial nephrectomy is feasible if two goals are met: resection of the mass with negative margins and control of bleeding. The latter is a particular challenge, but numerous options are available. The authors describe the operative technique and the available results of hand-assisted laparoscopic partial nephrectomy.     

Contemporary strategies for treating nonhereditary synchronous bilateral renal tumors and the impact of minimally invasive, nephron-sparing techniques

OBJECTIVES: As surgical technology and expertise advance, treatment strategies for patients with bilateral renal tumors will continue to shift toward methods that maximize preservation of renal function and maintain optimal oncologic outcomes while minimizing morbidity. Reports about such strategies are limited. We report the outcome of a contemporary cohort of patients treated for nonhereditary synchronous bilateral renal tumors at our institution to evaluate surgical strategies and newer techniques used during patient treatment. METHODS: From a surgical database, we identified 43 patients who met the criteria for nonhereditary, synchronous, bilateral renal tumors. Demographic characteristics, tumor pathology, renal function, surgical data, and outcomes were extracted from each patient's medical record. Computerized literature searches were performed to identify related articles for comparative purposes. RESULTS: Of the 43 patients, 36 (82%) were treated with staged procedures a median of 54 days apart. A total of 23 patients (53.3%) received bilateral nephron-sparing therapy, of whom 11 underwent a minimally invasive nephron-sparing approach. There was a median 28.0 ml/min decrease in creatinine clearance between initial preoperative levels and at last follow-up, with a median follow-up duration of 16 months, and no patient required dialysis. Of the 43 patients, 2 (4.7%) had local recurrences, and 1 (2.3%) had metastatic disease. CONCLUSION: These findings show a contemporary standard of care for treating patients with bilateral renal tumors, with more than half the patients undergoing bilateral nephron-sparing and nearly one third of patients receiving a minimally invasive nephron-sparing approach.     

Minimally invasive nephron-sparing surgery

Open partial nephrectomy, with its excellent 5- and 10-year oncologic follow-up data, is the gold standard against which all other nephron-sparing alternatives must be compared. The evolving minimally invasive nephron-sparing alternatives can essentially be divided into three categories: excision (laparoscopic partial nephrectomy), probe ablation (eg, cryotherapy, radiofrequency ablation), and noninvasive ablation (high-intensity focused ultrasound). A proposed algorithm for the evolving indications of minimally invasive nephron-sparing surgical options is presented in Fig. 23. Currently, by emulating the established techniques of open partial nephrectomy, laparoscopic partial nephrectomy has the most immediate clinical application and relevance. Emerging data support the efficacy and reproducibility of renal cryotherapy. Five-year follow-up data should be available in the near future. Although renal radiofrequency ablation has the potential to further minimize morbidity, serious concerns remain regarding the completeness of cancer cell kill and the reliability of intraoperative monitoring. Noninvasive technologic advancements such as high-intensity focused ultrasound have considerable potential for the future.     

Robot-assisted partial nephrectomy

Robot-assisted partial nephrectomy (RAPN) is a viable option for patients and surgeons who desire a minimally invasive alternative for the performance of nephron-sparing surgery (NSS). NSS has become the norm for the management of small renal masses. Numerous series have shown favorable outcomes for RAPN. RAPN has a shortened learning curve and eases the transition to minimally invasive NSS. We describe the indications, preparation, instrumentation, setup, technique, and complications for transperitoneal RAPN using a two- or three-arm approach. We also suggest strategies and tips so that surgeons early in the learning curve can effectively anticipate, avoid, and, if inevitable, manage complications.     

Robot-assisted partial nephrectomy: current status, techniques, and future directions

Open partial nephrectomy for the treatment of small renal masses (SRMs) concerning for renal cell carcinoma has been increasingly utilized with the increased incidental detection of SRMs and the growing recognition of the benefits of renal preservation. Laparoscopic partial nephrectomy (LPN) is a minimally invasive technique that achieves comparable oncologic and improved morbidity outcomes when compared to the open procedure. However, LPN is a technically demanding procedure resulting in a long learning curve and a lack of widespread adoption. Robot-assisted partial nephrectomy (RAPN) overcomes many of the technical hurdles of the LPN and is now coming to the forefront for the minimally invasive surgical management of SRMs. To date, the short-term oncologic outcomes of RAPN have been comparable to the open operation while providing the improved morbidity outcomes of LPN. Although encouraging, we await the long-term oncologic results of this new and promising procedure. The current bottleneck is an issue of cost and reliance on a patient-side surgeon. Future developments in instrumentation, newer robots, cost reduction, more streamlined training, increased robotic experience, and adoption by more centers will lead to greater benefit for patients with SRMs requiring nephron-sparing surgery. This review will discuss techniques for RAPN and then delve into the current status of RAPN using parameters such as warm ischemia time, blood loss, hospital stay, oncological outcomes, complications, learning curve, and quality of life. There will be an exploration of potential disadvantages associated with RAPN followed by a look at evolving techniques in regard to this groundbreaking procedure.     

Laparoscopic partial nephrectomy: contemporary technique and results

An increasing number of incidental small renal masses are being detected currently. In select patients, nephron-sparing surgery affords excellent oncologic outcomes with preservation of renal function. With the current trend towards minimally invasive surgery, development of a reliable laparoscopic partial nephrectomy technique has become a key issue. Over the past 4 years, the senior author has performed over 300 laparoscopic partial nephrectomies at the Cleveland Clinic. Herein we present our current technique and review contemporary results from the urologic literature.     

Nephron-sparing surgery--strategies for partial nephrectomy in renal cell carcinoma.

The use of partial nephrectomy for renal cell carcinoma has continuously changed in the clinical practice. Previously it was mostly used in imperative cases, in patients with a solitary kidney or in patients with a risk of renal failure. An increased number of incidentally detected renal cell carcinomas are diagnosed due to the advances of the radiological methods. These tumours tend to be smaller and generally with a lower stage. The reported excellent results of partial nephrectomy have promoted the use of nephron-sparing surgery also in patients with a normal contralateral kidney and tumours smaller than 4-5 cm. The technical outcome is excellent with a low operative morbidity and a good oncologic control. Therefore partial nephrectomy has become a standard technique in the treatment of properly selected patients. Laparoscopy with its reduced postoperative pain and shorter rehabilitation time, has encouraged the interest in minimally invasive nephron sparing surgical techniques. Although low, the risk of local tumour recurrence and surgical complications are higher after nephron-sparing surgery compared with radical nephrectomy. Furthermore, long-term renal function remains adequate in most patients with a normally functioning contralateral kidney also after radical nephrectomy. Albeit these facts, there is convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a small renal cell carcinoma and a normal functioning contralateral kidney.     

Laparoscopic partial nephrectomy and wedge resection for the treatment of renal malignancy

The widespread use of abdominal ultrasonography, CT, and MRI has led to an increase in the number of incidentally detected renal masses, some of which are malignant. Numerous studies suggest that partial nephrectomy or wedge resection of these lesions yield cure rates similar to those obtained with radical surgery. Laparoscopic nephron-sparing surgery is one of the more challenging minimally invasive surgical techniques, and its use is largely restricted to specialized medical centers. The techniques and available results are described.     

Minimally invasive nephron-sparing surgery (MINSS) for renal tumours part I: laparoscopic partial nephrectomy

OBJECTIVES: To review the evolution and current status of extirpative methods (laparoscopic partial nephrectomy [LPN]) of minimally invasive nephron-sparing surgery (MINSS) for renal tumors. METHODS: The English language literature of the past 10 yr was reviewed by using the National Library of Medicine database and the following keywords: kidney, laparoscopic partial nephrectomy, minimally invasive, nephron-sparing surgery, renal, and tumor. Over 275 papers were identified. Of these, 55 papers were selected for this review on the basis of their contribution in advancing the field with regards to (1) evolution of concepts, (2) development and refinement of techniques, and (3) intermediate- and long-term clinical outcomes of LPN. RESULTS: Open partial nephrectomy (OPN) is the reference standard for nephron-sparing surgery against which all MINSS techniques should be measured. With available skills for time-sensitive intracorporeal suturing, LPN provides perioperative results and long-term oncologic and functional outcomes comparable to the reference standard, with significantly decreased patient morbidity. The initial 5-yr data of 50 patients has just become available, and shows overall and cancer-specific survival of 84% and 100%, respectively. As global experience with this technique increases, data need to be prospectively accrued, and long-term cancer cure rates should be compared with the reference standard. CONCLUSIONS: As of this writing, the technique and global acceptance of LPN is evolving, although it remains restricted by the complexity of laparoscopic renal reconstruction. In expert hands, cancer cure and renal function outcomes are similar to OPN.     

Impact of Kidney Cancer Surgery on Oncologic and Kidney Functional Outcomes

Kidney cancer is a common genitourinary malignancy. The incidence of kidney cancer has progressively increased in the past few decades, with the greatest increase noted for incidentally discovered small renal masses. Along with the change in presentation and diagnosis of kidney cancer, surgical treatment of kidney cancer also has evolved dramatically during the past 5 decades, moving from universal use of radical extirpation to more frequent nephron-sparing and minimally invasive surgeries. This article reviews the contemporary management of localized kidney cancers and discusses the impact of surgery on oncologic and nononcologic outcomes.     

Retroperitoneoscopy-assisted cryoablation of renal tumors using multiple 1.5 mm ultrathin cryoprobes: a preliminary report

OBJECTIVES: Laparoscopic cryoablation has recently been proposed as a minimally invasive nephron-sparing treatment for selected patients. We report on our experience with a retroperitoneoscopic technique using multiple ultrathin cryoprobes. METHODS: Seven patients underwent retroperitoneoscopic renal cryoablation for solid renal masses. Mean tumor size on the CT scan was 2.6 (1.5-3.5) cm. A double freeze-thaw cycle of renal cryoablation was performed under real-time ultrasound monitoring using a total of six 1.5-mm cryoprobes simultaneously. RESULTS: Cryoablation was technically successful in all patients without any need for conversion. Mean duration of surgery was 161 (130-195) minutes and mean blood loss was 107 (50-250) ml. Perioperative biopsy of the tumor confirmed renal cell carcinoma in four patients and angiomyolipoma in two patients; it was inconclusive in one case. Mean follow-up for 13.6 (4-22) months showed no evidence of residual tumor or recurrence. CONCLUSIONS: Retroperitoneoscopy-assisted cryosurgical ablation using multiple ultrathin 1.5-mm cryoprobes is a minimally invasive treatment that is suitable to treat small renal tumors.     

Renal-artery pseudoaneurysm after laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy (LPN) has emerged as a minimally invasive treatment for small renal masses. The most common complications include hemorrhage and urinary-fistula formulation. Renal-artery pseudoaneurysm has been described after open nephron-sparing surgery. We present two cases of renal-artery aneurysm following LPN. CASE REPORTS: Two patients with incidentally discovered renal masses underwent LPN with excellent hemostasis and presented in a delayed fashion with gross hematuria and flank pain. Both patients were treated with angiographic coil embolization, resulting in resolution of the pseudoaneurysms on postprocedure imaging. CONCLUSIONS: Renal-artery pseudoaneurysm is a potentially life-threatening complication of LPN. Patients present in a delayed fashion with gross hematuria, flank pain, or both. The treatment of choice is angiography with selective coil embolization.     

Current practice patterns in the surgical management of renal cancer in the United States

Over the last two decades, there has been a rising incidence of renal tumors, particularly, small renal masses (<4 cm) resulting in a downward size and stage migration. This has brought about a paradigm shift in the management of newly diagnosed renal masses, such that nephron-sparing surgery, minimally invasive techniques, and active surveillance are frequently considered preferable to the historical gold standard of open radical nephrectomy. Population-based cohort studies indicate, however, that the widespread adoption of these techniques has been relatively slow and incomplete leading to significant disparities in the delivery of care throughout the country. Further investigation is required to determine the barriers to diffusion of new techniques and technology as well as to ensure equal access to quality care in the United States.     

The impact of renal surgery on global renal function and non-oncologic morbidity

Nephron preservation has been increasingly prioritized in the treatment of small renal tumors. Radical nephrectomy is now understood as a risk factor for development of chronic kidney disease, which is known to increase the risk of cardiovascular events and all-cause mortality. Indications for nephron-sparing surgery (NSS) have broadened from solitary kidney, bilateral tumors, and hereditary tumor syndromes to essentially all small renal tumors. Laparoscopic NSS has demonstrated excellent cancer control as well as good functional preservation despite the need for warm ischemia. There has been ongoing debate regarding safe parameters for warm ischemia, which are thought to vary with patient factors. Focal ablative therapies have been developed for use in high-risk surgical candidates (eg, radiofrequency ablation, cryoablation) to minimize renal and other treatment-related morbidity. Emphasis on minimally invasive approaches and advances in preventing renal dysfunction and other morbidity after NSS will guide the future of these therapies.