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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 -
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 -
Nature Reviews. Urology Aug 2011Ischemia-reperfusion injury caused by vascular clamping contributes to the decline in glomerular filtration rate following partial nephrectomy. Ischemia is the main... (Review)
Review
Ischemia-reperfusion injury caused by vascular clamping contributes to the decline in glomerular filtration rate following partial nephrectomy. Ischemia is the main modifiable factor that determines postoperative kidney function, and it is likely that a harmless duration of ischemia does not exist. Each additional minute of warm ischemia increases the odds of acute renal failure, severe chronic kidney disease (CKD) and end-stage renal disease. Our experience comparing partial nephrectomy with and without clamping in solitary kidneys suggests that renovascular clamping is the only statistically significant determinant of postoperative renal dysfunction. Studies comparing partial nephrectomy with and without clamping demonstrate that ischemia is associated with a risk of acute renal failure, advanced CKD, and renal replacement therapy. Oncologic outcomes and complications in partial nephrectomy without clamping are similar to those with clamping. Even in complex lesions, partial nephrectomy without vascular clamping is preferable when feasible.
Topics: Animals; Humans; Kidney Neoplasms; Nephrectomy; Nephrons; Surgical Instruments
PubMed: 21811227
DOI: 10.1038/nrurol.2011.103 -
International Urology and Nephrology Dec 2015Renal cell carcinoma (RCC) accounts for 3 % of adult solid tumors, with the highest incidence between 50 and 70 years of age. Nephron-sparing surgery was initially... (Review)
Review
Renal cell carcinoma (RCC) accounts for 3 % of adult solid tumors, with the highest incidence between 50 and 70 years of age. Nephron-sparing surgery was initially reserved to patients with small renal masses detected in anatomically or functionally solitary kidney or in the presence of multiple bilateral tumors or hereditary forms of RCC, which posed a high risk of developing a tumor in the contralateral kidney. Nowadays, partial nephrectomy (PN) has grown up to an established approach for the treatment of small renal masses. In patients with T1a-staged RCCs, PN has proven to be associated with better survival, long-term renal function preservation with lower dialysis need or renal transplantation. Currently, most of the kidney masses are incidentally detected, up to 40 %, with smaller size due to the widespread use of imaging modalities such as ultrasound, computed tomography and magnetic resonance. Here we review the role of open PN in the management of small renal masses particularly focusing on indications, oncological outcomes and comparison with laparoscopic and robotic PN. Recent studies demonstrate that PN confers better survival, oncologic equivalence and lower risk of severe chronic kidney disease compared to radical nephrectomy becoming then the gold-standard surgical technique, even if increasingly challenged by laparoscopic and/or robot-assisted partial nephrectomy which in the hands of experts seems to achieve comparable outcome results albeit with slightly higher complication rate.
Topics: Carcinoma, Renal Cell; Costs and Cost Analysis; Humans; Kidney Neoplasms; Laparoscopy; Nephrectomy; Organ Sparing Treatments; Patient Selection; Robotic Surgical Procedures; Survival Rate
PubMed: 26438327
DOI: 10.1007/s11255-015-1120-z -
The Journal of Urology Oct 1995We evaluate whether partial nephrectomy can be performed safely and efficaciously for renal tumors. (Clinical Trial)
Clinical Trial Review
PURPOSE
We evaluate whether partial nephrectomy can be performed safely and efficaciously for renal tumors.
MATERIALS AND METHODS
The results of 67 partial nephrectomies performed between 1977 and 1994 for renal cell carcinoma (51), oncocytoma (9), angiomyolipoma (3), transitional cell carcinoma (3) and other nonneoplastic lesions (2) were analyzed retrospectively in detail.
RESULTS
Diminished complication rates were noted after 1988, and were attributed to improvements in surgical technique and an increased incidence of smaller, serendipitously discovered tumors. Although 35.5% of the patients had preoperative renal impairment (mean serum creatinine 2.1 mg./dl.), there were minimal changes in renal function and no patient required acute hemodialysis following partial nephrectomy. Among 42 patients with clinical stage T1 to T2 renal cell carcinoma undergoing partial nephrectomy local recurrence was identified in 8.3% of those with primary neoplasms. All 6 patients with local recurrence had negative surgical margins, recurrence often, distant from the operative site and multifocal disease, implicating multicentricity as the etiology of local recurrence. Five patients (83.3%) with local recurrence were alive and asymptomatic at a mean of 138 months after partial nephrectomy. Since capsular penetration was identified in 5 of 27 renal cell carcinomas (18.5%) with a diameter of 3.5 cm. or less, aggressive surgical resection with adequate tumor-free parenchymal and perinephric margins is necessary even for small lesions.
CONCLUSIONS
With improved surgical techniques, including regional hypothermia, intraoperative sonography, meticulous dissection and injection of the collecting system with methylene blue, partial nephrectomy is safe and effective in properly selected patients.
Topics: Adolescent; Adult; Aged; Carcinoma, Renal Cell; Female; Follow-Up Studies; Humans; Kidney Neoplasms; Male; Middle Aged; Neoplasm Recurrence, Local; Nephrectomy; Renal Insufficiency; Urinary Fistula
PubMed: 7658526
DOI: 10.1016/s0022-5347(01)66845-9 -
ANZ Journal of Surgery Jun 2008Laparoscopic radical nephrectomy and open partial nephrectomy are now established methods of treatment for appropriate renal lesions suspicious for malignancy,... (Review)
Review
BACKGROUND
Laparoscopic radical nephrectomy and open partial nephrectomy are now established methods of treatment for appropriate renal lesions suspicious for malignancy, Laparoscopic partial nephrectomy has undergone progressive evolution. The aim of this paper is to; (i) evaluate the current status of laparoscopic partial nephrectomy, and (ii) to place it in the Australian and New Zealand context by evaluating the necessary skill acquisition for advanced laparoscopic urology.
METHODS
The National Library of Medicine database (PubMed) was used to specifically search the available literature on laparoscopic partial nephrectomy, renal failure and nephrectomy, modular surgical training and laparoscopic training. Of the articles identified, selection was based on their contribution to the development of techniques, progressive clinical outcomes, as well as comparisons with current management.
RESULTS
The technique and outcomes of laparoscopic partial nephrectomy are now secure enough to treat anatomically complex tumours in laparoscopically experienced hands. For the appropriate patient with a small renal mass, the impact of radical nephrectomy and long-term renal dysfunction needs to be considered, even in the presence of a normal contra-lateral kidney. Robotic assisted laparoscopic surgery is expensive and may impair the acquisition of advanced iaparoscopic skills.
CONCLUSION
Over the past 5 years, laparoscopic partial nephrectomy has developed to the stage where, with the necessary laparoscopic skill, it is now a standard of care at tertiary referral institutions. Widespread dissemination of advanced laparoscopic skills remains the next challenge.
Topics: Australia; Humans; Kidney Neoplasms; Laparoscopy; Nephrectomy; New Zealand; Robotics
PubMed: 18522568
DOI: 10.1111/j.1445-2197.2008.04537.x -
BJU International May 2010
Review
Topics: History, 20th Century; History, 21st Century; Humans; Kidney Neoplasms; Nephrectomy; Tumor Burden
PubMed: 20500566
DOI: 10.1111/j.1464-410X.2010.09339.x -
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 -
Current Opinion in Urology Sep 2013Laparoscopic and robotic-assisted partial nephrectomy have been widely adopted for the management of small renal masses; however, usage in T1b (greater than 4 cm)... (Review)
Review
PURPOSE OF REVIEW
Laparoscopic and robotic-assisted partial nephrectomy have been widely adopted for the management of small renal masses; however, usage in T1b (greater than 4 cm) lesions is less established. Herein, we report a review on the published series of minimally invasive partial nephrectomies for such renal masses.
RECENT FINDINGS
Several institutions have described laparoscopic and robotic-assisted partial nephrectomy as a safe management option for pathologic T1b lesions. The oncologic results are promising, with low positive margin rates and few cases of progressive disease. Longer-term renal dysfunction does not appear at an increasing rate in this cohort of patients. The safety profile appears acceptable; however, there is a slightly increased rate of complications in these cohorts of patients.
SUMMARY
Laparoscopic and robotic-assisted partial nephrectomy is a well tolerated and viable option for performing minimally invasive surgical extirpation of cT1b renal masses. The oncologic and functional results are excellent with acceptable safety profiles. In patients with such masses minimally invasive partial nephrectomy should be considered for elective and absolute indications. In order to achieve excellent functional and oncologic outcomes with minimal perioperative complications an experienced surgeon with assistant and assessment of tumor with patient comorbidities are important.
Topics: Humans; Kidney Neoplasms; Laparoscopy; Neoplasm Staging; Nephrectomy; Postoperative Complications; Risk Factors; Robotics; Surgery, Computer-Assisted; Treatment Outcome; Tumor Burden
PubMed: 23880738
DOI: 10.1097/MOU.0b013e32836320d2 -
Journal of Pediatric Urology Aug 2022Robotic partial nephrectomy is a complex minimally invasive procedure that addresses the intricate anatomy of renal masses while maximizing preservation of renal...
INTRODUCTION
Robotic partial nephrectomy is a complex minimally invasive procedure that addresses the intricate anatomy of renal masses while maximizing preservation of renal function. However, while common in adults, the evolution toward these minimally invasive procedures for children has been slow due to the anticipated technical difficulties in pediatric-sized working spaces. We present our technique and our experience with pediatric robotic partial nephrectomies that were performed with our adult urology colleagues at a large free-standing children's hospital.
METHODS
The video describes our technique for a robotic right-sided partial nephrectomy in a 14-month-old male patient. The video highlights several steps of the procedure including positioning and port placement, tumor resection, and renorrhaphy.
RESULTS
Six pediatric patients underwent robotic partial nephrectomy with our associated adult urologic surgeons from January 2019 to January 2021. The surgical pathology revealed both benign as well as malignant diagnoses.
CONCLUSION
Robotic partial nephrectomy is a feasible minimally invasive procedure in children. The collaboration with adult minimally invasive urologic surgeons with extensive adult procedural experience is recommended to avoid potential complications with this technically challenging procedure in pediatric patients. Pediatric strategies for robotic port placement are often needed to accommodate the smaller size of pediatric patients as well as tumor size.
Topics: Adult; Humans; Male; Child; Infant; Robotic Surgical Procedures; Hospitals, Pediatric; Kidney Neoplasms; Nephrectomy; Robotics
PubMed: 35931605
DOI: 10.1016/j.jpurol.2022.06.029