Date Published: May 9, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Eugene J. Pietzak, Thomas J. Guzzo.
Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.
Partial Nephrectomy (PN) is the treatment of choice whenever feasible for enhancing renal masses [1–3]. For a multitude of reasons, PN has evolved from an operation performed in patients with an absolute indication for nephron sparing surgery (NSS) to avoid dialysis (solitary kidney, bilateral synchronous masses, or hereditary syndrome), to the preferred procedure for patients with renal masses <7 cm even with a normal contralateral kidney . PN has proven to provide equivalent oncological outcomes to radical nephrectomy (RN) for renal tumors <4 cm (T1a) and, even more recently, tumors <7 cm (T1b) [5–9]. Multiple retrospective studies have shown no difference between PN and RN with regard to cancer-specific survival and rate to distant metastasis at long-term follow-up, but with greater renal function perseveration with PN [9–13]. Furthermore, several retrospective studies associate PN with better overall survival compared to RN [10, 14–17]. However, further investigation is still needed as the only prospective randomized trial comparing PN with RN showed an overall survival advantage for RN when using a intention-to-treat analysis . Laparoscopic PN (LPN) is an acceptable alternative to open PN (OPN) for the treatment of T1 renal masses when performed by a skilled laparoscopic surgeon [1, 4], advances in surgical technique and the use of hemostatic agents have expanded the indications for LPN to more complex renal masses . At this time, no good randomized data exists on the optimal technique for minimally invasive partial nephrectomy. The choice of approach is likely to be influenced by the individual surgeon's training and comfort level, as much as patient and tumor characteristics. Many of the minimally invasive techniques described often mimic the steps of an OPN . A well-known drawback of laparoscopic surgery is the lack of tactile feedback it provides; this is particularly true with robotics. Although this is an area of active investigation, currently, this shortcoming increases the dependence on preoperative imaging and intraoperative visual cues . Several studies suggest a strong correlation between ischemic time and loss of renal function [73, 74]. This has led to the concept that every minute of ischemia counts . Various strategies have been pursued in an effort to reduce the impact of ischemia on renal function . Suturing is the most effective means of hemostasis and preventing urinary leak; however it is challenging and time-consuming [97, 98]. Several advances in laparoscopy have been applied to LPN to make suturing more practical. The utilization of Hem-o-lok clips and Lapra-Ty clips to replace some of the knots allows for a tight closure with suture that is efficient and secure [98, 99]. For similar reasons the use of barbed suture (Quill or V-Loc) is increasing in popularity for renorrhaphy . For the reasons previously described, the current AUA guidelines recommend that stage 1 renal masses be treated with PN over RN whenever feasible or advisable as judged by the treating surgeon . Clearly, the term “feasible” is subjective. Furthermore, studies show that PN remains underutilized [108–111], which is likely even more true for minimally invasive approaches . As the aforementioned advances in LPN continue to gain widespread acceptance, it is likely that more tumors will be treated by LPN in the future. Similarly, although current literature on LPN largely reflects the experience of skilled laparoscopic surgeons at centers of excellence, the previously described advances may narrow the proficiency gap to allow LPN to be performed routinely in community settings. PN is the standard of treatment for renal tumors due tor the preservation of long-term renal function compared to RN. However, PN currently remains underutilized. LPN offers several benefits over OPN but is more technically challenging and associated with a higher rate of perioperative complications. However, the advances in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents described previously will likely allow increasingly more complex renal tumors to be amenable to LPN. Source: http://doi.org/10.1155/2012/148952