Radiofrequency Ablation-Assisted Zero-Ischemia Robotic Laparoscopic Partial Nephrectomy: Oncologic and Functional Outcomes in 49 Patients

Radiofrequency-assisted, laparoscopic, clampless partial nephrectomy in patients with low-complexity small renal tumors: A retrospective cohort study

BACKGROUND

This single-center, retrospective study was performed to investigate the safety and efficacy of radiofrequency-assisted (RF), laparoscopic partial nephrectomy (PN) with zero ischemia in patients with low-complexity small renal tumors.

MATERIALS AND METHODS

Patients with small renal masses (SRMs) who underwent laparoscopic, clampless laparoscopic partial nephrectomy - radiofrequency assisted (LPN-RFA) between January 2016 and June 2020 were studied. Demographics, clinical and pathological characteristics, recurrence-free survival, and overall survival were recorded.

RESULTS

Fifty-two SRMs were excised from corresponding patients using RFA-LPN. The median tumor size was 2.5 cm and all specimens involved low-complexity masses according to the renal nephrometry score. No conversions to radical nephrectomy were recorded. Postoperatively, there were one patient with fever, one with hematuria, and two with urinary leakage treated endoscopically. The majority of tumors (48/52, 86.2%) were clear-cell carcinomas. According to the glomerular filtration rate postoperatively and 12 months' posttreatment, adequate renal function was preserved in all patients. There were no positive surgical margins identified postoperatively and no recurrences during a median follow-up 24 months. All patients were alive at the last follow-up.

CONCLUSIONS

This study suggests that RFA laparoscopic clampless PN represents an effective method for managing patients with low-complexity SRMs. It offers adequate intraoperative safety and excellent mid-term oncological control and functional preservation.

How to improve outcome in nephron-sparing surgery: the impact of new techniques

PURPOSE OF REVIEW

Nephron-sparing partial nephrectomy is the state of the art for localized small renal mass and it is gaining attention also for more advanced cases. In the present narrative review, we discuss the new developments that have occurred in the advancement of this approach over the past few years.

RECENT FINDINGS

Off-clamp, selective/superselective clamp and early-unclamping techniques are safe and feasible approaches, with potentially superior functional outcomes, and noninferior complications rate and oncological outcomes, when compared with main artery clamping. Renorrhaphy must preserve the physiological vascularization of residual parenchyma. Running sutures, particularly using barbed wires, shorten the operating and ischemia times. A further advantage could derive from avoiding a double-layer suture. Transperitoneal robot-assisted partial nephrectomy (RAPN) and retroperitoneal RAPN can be considered equivalent in terms of perioperative morbidity, functional and oncologic outcomes, regardless of tumor's location, thus the choice of the approach should be driven by the surgeon's expertise. Future improvements should be introduced by the single-port robotic surgery, which seems to be safe and feasibly also in an off-clamp manner.

SUMMARY

Significant advances have recently been achieved in nephron-sparing surgery technique. However, future studies with standardized reporting of these new techniques are needed to assess the real impact of them on early and long-term functional outcomes.

Zero ischemia laparoscopic microwave ablation assisted enucleation vs. laparoscopic partial nephrectomy in clinical T1a renal tumor: a randomized clinical trial

Background

The study aims to evaluate efficiency, safety and the functional outcomes of zero ischemia laparoscopic microwave ablation assisted tumor enucleation (LMWATE) in comparison with laparoscopic partial nephrectomy (LPN) for cT1a renal tumors.

Methods

A prospective randomized controlled trial on cT1a renal tumor patients treated by laparoscopic nephron sparing surgeries between October 2014 to September 2017 was conducted. Tumor enucleation was performed in the LMWATE group after microwave ablation (MWA) without hilar clamping. The endpoint was the affected kidney's change of GFR measured by renal scintigraphy at the 3rd month and 12th month postoperatively. All the patients were followed up for at least 12 months. The Student t-test, Wilcoxon rank sum tests and Pearson Chi-square or Fisher exact were applied to analyse data.

Results

The number of patients enrolled in the LMWATE group and LPN group were 90 and 93 respectively. Patients in the LPN group showed much more decline of effect kidney glomerular filtration rate at 3 months (10.3 vs. 17.4, P<0.001) and 12 months postoperatively (8.8 vs. 10.2, P=0.023) when compared to the LMWATE group. Additionally, in the LMWATE group, considerably shorter median operation duration (91 vs. 112 minutes, P<0.001), lower median estimated blood loss (82.5 vs. 117.5 mL, P<0.001) and shorter hospital stay (5.5 vs. 6 days, P=0.013) were observed but with similar postoperative complications in both groups. There was no positive margin or local recurrence in both groups.

Conclusions

Zero ischemia LMWATE may provide better preservation of renal function, decrease operative time and blood loss compared to LPN with similar complication rates.

Long-term renal function following zero ischemia partial nephrectomy

Partial nephrectomy (PN), also known as nephron sparing surgery, is considered as the first-line treatment in small renal masses, especially in T1/2 tumors, and is applied as a standard treatment in advanced centers. The main expected outcomes from an ideal PN are surgical margin negativity, minimal impairment in renal function, and any surgical complications. Many authors have defined PN techniques as “zero ischemia partial nephrectomy”, where surgery is performed without clamping the main renal artery in order to protect the renal parenchyma from ischemic injury. Various PN techniques employed by surgeons include: selective or segmental renal artery clamping technique; off-clamp, clampless, or unclamped technique; preoperative superselective transarterial tumor embolization technique; sequential/modified sequential preplaced suture renorrhaphy technique, radio frequency ablation-assisted technique, and combination of these techniques. The common goal of all these techniques is to provide zero ischemia without hilar clamping. This systematic review focuses on the long-term functional outcomes of PNs performed by zero ischemia techniques.