Using a Harmonic Scalpel "Drilling and Clamping" Method to Implement Zero Ischemic Robotic-assisted Partial Nephrectomy: An Observation Case Report Study

Microwave Scissors-Based Sutureless Laparoscopic Partial Nephrectomy Versus Conventional Open Partial Nephrectomy in a Porcine Model: Usefulness and Complications

BACKGROUND

This study aimed to compare the benefits and safety of microwave scissors-based sutureless laparoscopic partial nephrectomy (MSLPN) with those of conventional open partial nephrectomy (cOPN).

METHODS

Each kidney in nine pigs underwent MSLPN using microwave scissors (MWS) via transperitoneal laparoscopy or cOPN via retroperitoneal open laparotomy. The kidney's lower and upper poles were resected under temporary hilar-clamping. The renal calyces exposed during renal resections were sealed and transected using MWS in MSLPN and were sutured in cOPN. For MWS, the generator's power output was 60 W. Data on procedure time (PT), ischemic time (IT), blood loss (BL), normal nephron loss (NNL), and extravasation during retrograde pyelogram were compared between the two techniques.

RESULTS

The authors successfully performed 22 MSLPNs and 10 cOPNs. Compared with cOPN, MSLPN was associated with significantly lower PT (median, 9.2 vs 13.0 min; p = 0.026), IT (median, 5.9 vs 9.0 min; p < 0.001), BL (median, 14.4 vs 38.3 mL; p = 0.043), and NNL (median, 7.6 vs 9.4 mm; p = 0.004). However, the extravasation rate was higher in the MSLPN group than in the cOPN group (54.5 % [n = 12] vs 30.0 % [n = 3]), albeit without a significant difference (p = 0.265). Pelvic stenosis occurred in one MSLPN procedure that involved deep lower pole resection near the kidney hilum.

CONCLUSIONS

The study data show that MSLPN can improve intraoperative outcomes while reducing technical demands for selected patients with non-hilar-localized renal tumors. However, renal calyces, if violated, should be additionally sutured to prevent urine leakage.

Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective

In recent years, there was an abrupt increase in the incidence of renal tumors, which prompt up the appearance of cutting-edge technology, including minimally invasive and organ-preserving approaches, such as laparoscopic partial nephrectomy (LPN). LPN is an innovative technique used to treat small renal masses that have been gaining popularity in the last few decades due to its promissory results. However, the bleeding control remains the main challenge since the majority of currently available hemostatic agents (HAs) used in other surgical specialities are inefficient in LPN. This hurried the search for effective HAs adapted for LPN surgical peculiarities, which resulted on the emergence of different types of topical HAs. The most promising are the natural origin HAs because of their inherent biodegradability, biocompatibility, and lowest toxicity. These properties turn them top interests' candidates as HAs in LPN. In this review, we present a deep overview on the progress achieved in the design of HAs based on natural origin polymers, highlighting their distinguishable characteristics and providing a clear understanding of their hemostat's role in LPN. This way it may be possible to establish a structure-composition properties relation, so that novel HAs for LPN can be designed to explore current unmet medical needs.

Ischemia Techniques in Nephron-sparing Surgery: A Systematic Review and Meta-Analysis of Surgical, Oncological, and Functional Outcomes

CONTEXT

The optimal ischemia technique at partial nephrectomy (PN) for renal masses is yet to be determined.

OBJECTIVE

To summarize and analyze the current evidence about surgical, oncological, and functional outcomes after different ischemia techniques (cold, warm, and zero ischemia) at PN.

EVIDENCE ACQUISITION

A computerized systematic literature search was performed by using PubMed (MEDLINE) and Science Direct. Identification and selection of the studies were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria. Outcomes of interest were estimated blood loss (EBL), overall complications, positive surgical margins, local tumor recurrence, and renal function preservation. Meta-analysis and forest-plot diagrams were performed. Overall pooled estimates, together with 95% confidence intervals (CIs), of the incidence of all parameters were obtained using a random effect model (RE-Model) on the log transformed means (MLN), proportion, or standardized mean change, as deemed appropriate.

EVIDENCE SYNTHESIS

One hundred and fifty-six studies were included. No clinically meaningful differences were found in terms of EBL after cold (mean: 215.5; 95% CI: 154.2-276.8m), warm (mean: 201.8; 95% CI: 175.0-228.7ml), or zero (mean: 261.2; 95% CI: 171.0-351.3ml) ischemia technique. Overall, postoperative complications were recorded in 14.1% (95% CI: 6.7-27.4), 11.1% (95% CI: 10.0-12.3), and 9.7% (95% CI: 7.7-12.2) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Positive surgical margins were recorded in 4.8% (95% CI: 1.9-10.9), 4.0% (95% CI: 3.4-4.8), and 5.6% (95% CI: 3.1-9.8) of patients after cold, warm, and zero ischemia (p<0.01), respectively. Local recurrence was recorded in 3.2% (95% CI: 1.9-5.2) and 3.1% (95% CI: 0.7-11.5) of patients after warm and zero ischemia (p<0.01), respectively. The log₂ of estimated glomerular filtration ratio mean changes were-1.37 (95% CI:-3.42 to 0.68),-1.00 (-2.04 to 0.03), and-0.71 (-1.15 to-0.27) ml/min after cold, warm, and zero ischemia, respectively. Low level of evidence, retrospective nature of most of included studies, a high risk of selection bias, and heterogeneity within included studies limited the overall quality of the analysis.

CONCLUSIONS

The effect of ischemia technique at PN is still debatable and subject to confounding by several factors, namely, patients' selection criteria, surgical technique used, and percentage of functional parenchyma spared during surgery. These confounders bias available evidence and were addressed by only a small part of available studies. Unfortunately, the overall quality of literature evidences and the high risk of selection bias limit the possibility of any causal interpretation about the relationship between the ischemia technique used and surgical, oncological, or functional outcomes. Thus, none of the available ischemia technique could be recommended over the other.

PATIENT SUMMARY

The present analysis shows that none of the available ischemia techniques, namely, cold, warm, or zero ischemia, is universally superior to the others, and other factors play a role in the surgical outcome.

Robot-assisted partial nephrectomy: systematic review of functional results

PURPOSE OF REVIEW

Various ischemia type during partial nephrectomy for renal cell cancer (RCC) resulted in different postoperative functional outcomes. Our objective was to systematically review the contemporary literature on robot-assisted partial nephrectomy (RPN) and investigate the association of ischemia type and tumor complexity with postoperative functional outcomes of the operated kidney and overall.

RECENT FINDINGS

Forty-five of the 99 reports identified were selected for qualitative analysis. All included studies were observational and nonrandomized. Overall, we found that patients undergoing RPN with zero ischemia and selective artery clamping had a lower decrease in glomerular filtration rates of the operated kidney in comparison to both warm and cold ischemia. This association seems also to play a role in patients with bilateral kidneys harboring complex tumors.

SUMMARY

Zero ischemia and selective artery clamping provide the best functional outcomes following robotic partial nephrectomy. This seems to be of particular relevance in patients with single kidney or tumors of high complexity. Whether these changes are statistically or clinically significant cannot be determined within this systematic review.