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European Urology Dec 2015A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. (Review)
Review
CONTEXT
A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes.
OBJECTIVE
To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN).
EVIDENCE ACQUISITION
A literature review was conducted.
EVIDENCE SYNTHESIS
Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration.
CONCLUSIONS
Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications.
PATIENT SUMMARY
In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes.
Topics: Humans; Kidney; Nephrectomy
PubMed: 25911061
DOI: 10.1016/j.eururo.2015.04.010 -
The Urologic Clinics of North America May 2017The incidence of the small renal mass continues to increase owing to the aging population and the ubiquity imaging. Most of these tumors are stage I tumors. Management... (Review)
Review
The incidence of the small renal mass continues to increase owing to the aging population and the ubiquity imaging. Most of these tumors are stage I tumors. Management strategies include surveillance, ablation, and extirpation. There is a wide body of literature favoring nephron-sparing approaches. Although nephron-sparing surgery may yield decreased long-term morbidity, it is not without its drawbacks, including a higher rate of complications. Urologists must be attuned to the complications of surgery and develop strategies to minimize risk. This article reviews expected complications of surgery on renal masses and risk stratification schema.
Topics: Humans; Kidney Neoplasms; Medical Errors; Nephrectomy; Postoperative Complications; Risk Assessment; Tumor Burden
PubMed: 28411919
DOI: 10.1016/j.ucl.2016.12.013 -
International Journal of Surgery... Dec 2016Innovation in recent times has accelerated due to factors such as the globalization of communication; but there are also more barriers/safeguards in place than ever... (Review)
Review
Innovation in recent times has accelerated due to factors such as the globalization of communication; but there are also more barriers/safeguards in place than ever before as we strive to streamline this process. From the first planned partial nephrectomy completed in 1887, it took over a century to become recommended practice for small renal tumours. At present, identified areas for improvement/innovation are 1) to preserve renal parenchyma, 2) to optimise pre-operative eGFR and 3) to reduce global warm ischaemia time. All 3 of these, are statistically significant predictors of post-operative renal function. Urologists, have a proud history of embracing innovation & have experimented with different clamping techniques of the renal vasculature, image guidance in robotics, renal hypothermia, lasers and new robots under development. The DaVinci model may soon no longer have a monopoly on this market, as it loses its stranglehold with novel technology emerging including added features, such as haptic feedback with reduced costs. As ever, our predictions of the future may well fall wide of the mark, but in order to progress, one must open the mind to the possibilities that already exist, as evolution of existing technology often appears to be a revolution in hindsight.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Radiography, Interventional; Robotic Surgical Procedures; Treatment Outcome
PubMed: 26975430
DOI: 10.1016/j.ijsu.2016.03.024 -
Current Urology Reports Jan 2018Laparoscopic kidney surgery is commonly used for living donor, partial, and total tumor nephrectomy. The successful emergence of laparoscopic technique was justified by... (Review)
Review
PURPOSE OF REVIEW
Laparoscopic kidney surgery is commonly used for living donor, partial, and total tumor nephrectomy. The successful emergence of laparoscopic technique was justified by the many benefits offered such as reduced blood loss, tissue trauma, pain, and hospital stay. However, this comes at the expense of physiologic changes and complications secondary to pneumoperitoneum, surgical technique, and patient positioning with significant challenges in anesthetic management.
RECENT FINDINGS
A variety of laparoscopic approaches (transperitoneal, retroperitoneal, hand-assisted, robotic) are used with some having advantages over others. The kidneys are particularly sensitive to hemodynamic changes and pneumoperitoneum. Controversies in perioperative fluid administration exist. New modalities for postoperative pain control have been suggested. Laparoscopic kidney surgery is associated with multiple physiologic changes and adverse events but offers advantages of reduced postoperative pain, faster recovery, and shorter hospital stay. Understanding these physiologic changes and related anesthetic considerations is key for safe patient outcome.
Topics: Anesthesia, General; Humans; Kidney; Laparoscopy; Monitoring, Intraoperative; Nephrectomy; Pain, Postoperative; Patient Positioning; Perioperative Care; Pneumoperitoneum, Artificial
PubMed: 29349580
DOI: 10.1007/s11934-018-0757-4 -
International Journal of Surgery... Dec 2016Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not... (Review)
Review
Although most partial nephrectomies are performed as primary procedures in the elective or semi-imperative setting on kidneys with relatively normal anatomy, this is not always the case. The indications for partial nephrectomy continue to expand and it is becoming particularly relevant in patients with single functioning kidneys, poor kidney function, anatomical anomalies and hereditary syndromes predisposing to multiple kidney cancers, such as Von Hippel-Lindau syndrome. These, along with previous abdominal surgery, pose surgical challenges. In this article we offer advice as to how to tackle these unusual situations. An ability to master the whole range of indications will allow the modern upper renal tract surgeon to offer partial nephrectomy to a wider range of patients.
Topics: Abdomen; Carcinoma, Renal Cell; Humans; Kidney; Kidney Neoplasms; Nephrectomy; Syndrome; von Hippel-Lindau Disease
PubMed: 27262880
DOI: 10.1016/j.ijsu.2016.05.070 -
Urologia Internationalis 2018To contrast the clinical effects and complications for the treatment of T1 renal carcinoma in partial nephrectomy (PN) and radical nephrectomy (RN). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To contrast the clinical effects and complications for the treatment of T1 renal carcinoma in partial nephrectomy (PN) and radical nephrectomy (RN).
METHODS
Multiple databases were adopted to search relevant studies, and articles that eventually satisfied the inclusion criteria were included. All meta-analyses were conducted with the Review Manager 5.0, and to estimate the quality of each article, risk of bias table was performed.
RESULTS
In the end, 13 studies including 13,269 patients were involved, which eventually satisfied the eligibility criteria. The number of samples in the PN group and the RN group were 6,145 and 7,124 respectively. The results of heterogeneity test suggested that the operating time (mean difference [MD] = -13.02, 95% CI [-14.15 to -11.89], p < 0.00001; p for heterogeneity < 0.00001, I2 = 100%), glomerular filtration rate (GFR) at 24 h after surgery (MD = 11.28, 95% CI [10.71-11.85], p < 0.00001; p for heterogeneity < 0.000001, I2 = 98%), and recurrence (OR 0.99, 95% CI [0.51-1.93], p = 0.97; p for Heterogeneity = 0.73, I2 = 0%) were significantly different, while differences in GFR at 24 h before surgery (MD = 0.59, 95% CI [0.06-1.12], p = 0.03; p for heterogeneity < 0.000001, I2 = 76%) between PN and RN were insignificant.
CONCLUSION
This study demonstrated that clinical efficacy of RN was better than that of PN to some extent, but PN was a quicker recovery and less harmful therapy.
Topics: Adult; Aged; Carcinoma, Renal Cell; Female; Humans; Kidney Neoplasms; Male; Middle Aged; Neoplasm Staging; Nephrectomy; Risk Factors; Treatment Outcome
PubMed: 30089288
DOI: 10.1159/000490576 -
The Journal of Urology Jun 2015Partial nephrectomy is the reference standard for the management of small renal tumors and is commonly used for localized kidney cancer. A primary goal of partial... (Review)
Review
PURPOSE
Partial nephrectomy is the reference standard for the management of small renal tumors and is commonly used for localized kidney cancer. A primary goal of partial nephrectomy is to preserve as much renal function as possible. New baseline glomerular filtration rate after partial nephrectomy can have prognostic significance with respect to long-term outcomes. Recent studies provide an increased understanding of the factors that determine functional outcomes after partial nephrectomy as well as preventive measures to minimize functional decline. We review these advances, highlight ongoing controversies and stimulate further research.
MATERIALS AND METHODS
A comprehensive literature review consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria was performed from January 2006 to April 2014 using PubMed®, Cochrane and Ovid Medline. Key words included partial nephrectomy, renal function, warm ischemia, hypothermia, nephron mass, parenchymal volume, surgical approaches to partial nephrectomy, preoperative and intraoperative imaging, enucleation, hemostatic agents and energy based resection. Relevant reviews were also examined as well as their cited references. An additional Google Scholar search was conducted to broaden the scope of the review. Only English language articles were included in the analysis. The primary outcomes of interest were the new baseline level of function after early postoperative recovery, percent decline in function, potential etiologies and preventive measures.
RESULTS
Decline in function after partial nephrectomy averages approximately 20% in the operated kidney, and can be due to incomplete recovery from the ischemic insult or loss of nephron mass related to parenchymal excision or collateral damage during reconstruction. Compensatory hypertrophy in the contralateral kidney after partial nephrectomy in adults is marginal and decline in global renal function for patients with 2 kidneys averages about 10%, although there is some variance based on tumor size and location. Irreversible ischemic injury can be minimized by pharmacological intervention or surgical approaches such as hypothermia, limited warm ischemia, or zero or segmental ischemia. Excessive loss of nephron mass can be minimized by improved preoperative or intraoperative imaging, use of a bloodless field, enucleation and vascular microdissection. Hemostatic agents or energy based resection that minimizes the need for parenchymal and capsular suturing can also optimize preservation of the vascularized nephron mass.
CONCLUSIONS
Our understanding of the decline in renal function after partial nephrectomy has advanced considerably, including better appreciation of its magnitude and impact in various settings, possible etiologies and potential preventive measures. Many controversies persist and this remains an important area of investigation.
Topics: Humans; Kidney; Nephrectomy; Reperfusion Injury
PubMed: 25637858
DOI: 10.1016/j.juro.2015.01.093 -
European Urology Oncology Apr 2023
Topics: Humans; Nephrectomy; Kidney
PubMed: 36717333
DOI: 10.1016/j.euo.2023.01.007 -
European Urology May 2015
Topics: Humans; Laparoscopy; Nephrectomy; Robotic Surgical Procedures; Robotics
PubMed: 25649530
DOI: 10.1016/j.eururo.2015.01.019 -
Current Urology Reports Feb 2016Small renal masses (SRMs) have been traditionally managed with surgical resection. Minimally invasive nephron-sparing treatment methods are preferred to avoid harmful... (Review)
Review
Small renal masses (SRMs) have been traditionally managed with surgical resection. Minimally invasive nephron-sparing treatment methods are preferred to avoid harmful consequences of renal insufficiency, with partial nephrectomy (PN) considered the gold standard. With increase in the incidence of the SRMs and evolution of ablative technologies, percutaneous ablation is now considered a viable treatment alternative to surgical resection with comparable oncologic outcomes and better nephron-sparing property. Traditional thermal ablative techniques suffer from unique set of challenges in treating tumors near vessels or critical structures. Irreversible electroporation (IRE), with its non-thermal nature and connective tissue-sparing properties, has shown utility where traditional ablative techniques face challenges. This review presents the role of IRE in renal tumors based on the most relevant published literature on the IRE technology, animal studies, and human experience.
Topics: Animals; Electroporation; Humans; Kidney Neoplasms; Nephrectomy
PubMed: 26769468
DOI: 10.1007/s11934-015-0571-1