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International Journal of Urology (2014) 21, 865–873
doi: 10.1111/iju.12470
Original Article: Clinical Investigation
Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: Single-surgeon series Wasilijiang Wahafu, Xin Ma, Hong-Zhao Li, Qiang Ding, Bao-Jun Wang, Tao-Ping Shi, Tao Zheng, Jun Dong, Wei Cai and Xu Zhang Department of Urology, Military Postgraduate Medical College, Chinese People’s Liberation Army General Hospital, Beijing, China
Abbreviations & Acronyms ASA = American Society of Anesthesiologists BMI = body mass index BUN = blood urea nitrogen CCI = Charlson Comorbidity Index EBL = estimated blood loss ECOG PS = Eastern Cooperative Oncology Group performance status eGFR = estimated glomerular filtration rates GFR = glomerular filtration rates LPN = laparoscopic partial nephrectomy OLIF = one layer, interrupted, figure-of-eight sCr = serum creatinine TLCU = two layers, continuous, unknotted WIT = warm ischemia time Correspondence: Xu Zhang M.D., Department of Urology, Military Postgraduate Medical College, Chinese People’s Liberation Army General Hospital, No. 28, Fu Xing Road, Beijing 100853, China. Email: [email protected] Received 8 January 2014; accepted 19 March 2014. Online publication 29 April 2014
Objectives: To evaluate renorrhaphy techniques and to analyze surgical outcomes in retroperitoneal laparoscopic partial nephrectomy. Methods: A retrospective study from January 2008 to December 2011 analyzed 526 patients with renal tumors in whom renorrhaphy was changed from one layer, interrupted, figure-of-eight (n = 228) suture to two layers, continuous, unknotted (n = 298) suture. All procedures were carried out by the same laparoscopic surgeon (XZ). Patient demographics, tumor characteristics, operative outcomes and perioperative renal function were compared. Results: Median follow up for one layer, interrupted, figure-of-eight suture and two layers, continuous, unknotted suture was 31 and 28 months, respectively. The two layers, continuous, unknotted suture group had shorter warm ischemia time (P = 0.021), faster removal of Jackson-Pratt drains (P = 0.029) and shorter hospital stay (P = 0.037) than the one layer, interrupted, figure-of-eight suture group. There was a trend towards a better preservation of glomerular filtration rates in the two layers, continuous, unknotted suture group (P = 0.045). In a multivariable model, the two layers, continuous, unknotted suture technique was a statistically significant independent predictor of warm ischemia time (P = 0.01), hospital stay (P = 0.001) and estimated glomerular filtration rates (P = 0.043). Conclusions: Two layers, continuous, unknotted suture renorrhaphy allows better outcomes than one layer, interrupted, figure-of-eight suture renorrhaphy in retroperitoneal laparoscopic partial nephrectomy. A longer clinical follow-up evaluation is warranted.
Key words: outcomes, partial nephrectomy, renal tumors, renorrhaphy, retroperitoneal laparoscopy.
Introduction LPN has generally been considered to be the standard for appropriate renal tumors.1–5 The approach of LPN, namely transperitoneal or retroperitoneal, is primarily based on the individual surgeon’s experience and preference, tumor location, and tumor size. Despite the relatively small space available for operating, the retroperitoneal approach offers excellent access to the renal artery, less bowel irritation, lower risk of organ injury and limited postoperative fluid in the retroperitoneum.6–8 However, regardless of the approach, the renorrhaphy technique applied is one of the key factors from a surgical standpoint that influences perioperative outcomes. Renorrhaphy is a very important technique for achieving adequate hemostasis and reconstruction of the kidney within a reasonable WIT during LPN. The most widely used renorrhaphy technique during partial nephrectomy bed is freehand laparoscopic suturing with or without adjunctive biological hemostatic agents. In a previous study, our group studied the use of an initial renorrhaphy in OLIF technique for retroperitoneal LPN.9 To date, there is another kind of notable renorrhaphy: the TLCU technique. When focusing on renorrhaphy technique options in retroperitoneal LPN, no studies comparing surgical effectiveness of OLIF and TLCU have been reported. The aim of the present study was to compare perioperative, functional, and oncological outcomes of OLIF and TLCU in patients undergoing retroperitoneal LPN.
Methods Patient selection From January 2008 to December 2011, a total of 1181 patients with organ-confined renal tumors in the Department of Urology, PLA Military Hospital of Beijing, Beijing, China, © 2014 The Japanese Urological Association
865
W WAHAFU ET AL.
(a)
(b)
(c)
(d)
(e)
(f) Fig. 1 (a) Port positioning for retroperitoneal LPN. (b) The renal artery is occluded with bulldog clamps. (c) Original OLIF technique placed over the hemostatic gauze. (d) Contemporary TLCU technique: a running suture oversewed the tumor excision bed. (e) One sliding Hem-o-lok clip secured the final throw on the renal capsule. (f) Two sutures were tied to each other after placing the last sliding Hemo-lok clip.
underwent LPN by a retroperitoneal approach. Patients treated with a transperitoneal approach (n = 68) during the same time period were excluded. All patients were assessed with either computed tomography or magnetic resonance imaging before operation. None of the patients were found to have metastatic disease. Of these patients, 567 were treated by the same laparoscopic surgeon (XZ). Patients who were missing clinical information (n = 12) or lost to follow up (n = 29) were excluded, leaving 526 patients available for analysis. These patients had undergone either type of renorrhaphy technique: 228 patients underwent OLIF, and 298 patients underwent TLCU.
Surgical technique Technique for OLIF Our renorrhaphy technique of OLIF has been previously described.9 In short, the patient was placed in the modified flank position, and three trocars were placed to complete the dissection from the retroperitoneal approach (Fig. 1a). Artery-only clamping was carried out (Fig. 1b). Intraoperative ultrasonography was mostly used to confirm the location, width and depth of the endophytic tumor. Once complete tumor resection was verified using the laparoscopic shears, the harmonic scalpel could be used to control parenchymal surface oozing and bleeding from small interlobar vessels. An interrupted figure-of-eight suture was used when the colleting system was entered. Adjunctive fibrin glue was applied, and a bolster might be omitted in select cases. The edges of the parenchyma were approximated with OLIF stitches using 0-Vicryl suture (Fig. 1c). The hilum was then unclamped and the renorrhaphy was inspected for hemostasis.
Technique for TLCU TLCU patients underwent all previously described steps up until the capsular renorrhaphy, where instead of OLIF the technique of TLCU was carried out. A 15-cm 2-0 Monocryl suture was tied to a Hem-o-lok clip at the free end and used as a running suture of the tumor excision bed to oversew larger 866
vessels as well as entries into the collecting system (Fig. 1d). Every three throws were placed in the longitudinal axis of the partial nephrectomy bed, and the suture was then gently pulled. The suture was brought through the renal capsule with the final throw and secured with one sliding Hem-o-lok clip (Fig. 1e). The renal capsule was re-approximated using a continuous, horizontal running 20-cm 0-Vicryl suture (tied to a Hem-o-lok clip the same as the first suture) with a sliding Hem-o-lok clip placed after the suture passed through the left side of capsule and readjusted the tension. After placing the last sliding Hemo-lok clip, the renal artery was unclamped and both needles were then removed from the suture. The renorrhaphy sutures were tied to each other (Fig. 1f).
Measurements Patient demographics (sex, age), clinical characteristics (BMI, ASA score, age-adjusted CCI, ECOG PS), tumor characteristics (tumor size, location, histology, pathological stage, Fuhrman grade, margin status), surgical characteristics (operative time, WIT, EBL, drain days, passing flatus days, length of hospital stay), postoperative complications (up to 30 days after surgery), oncological outcomes (recurrence rates and mortality) and renal function outcomes (sCr, BUN, eGFR) were retrospectively analyzed. Our operation time was from skin incision to closure. A further comparison of operative outcomes and renal function were carried out between the initial 50% cases and the last 50% patients in each group. The tumor was classified according to location on radiological imaging studies, when it was external to the line of the renal capsule it was considered exophytic when greater than 60%, mesophytic when 40–60% and endophytic when less than 40%.10 Postoperative complication data were collected using the modified Clavien scale.11 eGFR was calculated using the abbreviated equations of the Modification of Diet in Renal Disease for Chinese patients (in mL/min/ 1.73 m2) = 186 × sCr−1.154 × age−0.203 × 0.742 (if female) × 1.233 (if Chinese).12 We defined that the Jackson-Pratt drain could be removed when the drained volume was less than 30 mL, and patients could discharge 1 day after the removal of the JP drain. © 2014 The Japanese Urological Association
Evolving renorrhaphy technique
Follow-up and convalescence data were obtained by telephone contact.
Table 1
Patient characteristics
Variables
Statistical analysis The baseline characteristics of the OLIF and TLCU groups were compared using independent samples t-test for continuous variables. The χ2-test was used to estimate unordered categorical variables, and the Mann–Whitney U-test was used to adjust for ordinal categorical variables. For the multivariate analysis, the dependent variables as a continuous variable were evaluated using a generalized linear model. Response distribution was assumed to be normal distribution, and link function was identity. The independent variables as covariates were put into the multivariate analyzed model. As a main effect model, it did not join the interactive effects. All statistical analyses were carried out using SPSS 19.0 (SPSS, Chicago, IL, USA), and two-sided P-values
International Journal of Urology (2014) 21, 865–873
doi: 10.1111/iju.12470
Original Article: Clinical Investigation
Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: Single-surgeon series Wasilijiang Wahafu, Xin Ma, Hong-Zhao Li, Qiang Ding, Bao-Jun Wang, Tao-Ping Shi, Tao Zheng, Jun Dong, Wei Cai and Xu Zhang Department of Urology, Military Postgraduate Medical College, Chinese People’s Liberation Army General Hospital, Beijing, China
Abbreviations & Acronyms ASA = American Society of Anesthesiologists BMI = body mass index BUN = blood urea nitrogen CCI = Charlson Comorbidity Index EBL = estimated blood loss ECOG PS = Eastern Cooperative Oncology Group performance status eGFR = estimated glomerular filtration rates GFR = glomerular filtration rates LPN = laparoscopic partial nephrectomy OLIF = one layer, interrupted, figure-of-eight sCr = serum creatinine TLCU = two layers, continuous, unknotted WIT = warm ischemia time Correspondence: Xu Zhang M.D., Department of Urology, Military Postgraduate Medical College, Chinese People’s Liberation Army General Hospital, No. 28, Fu Xing Road, Beijing 100853, China. Email: [email protected] Received 8 January 2014; accepted 19 March 2014. Online publication 29 April 2014
Objectives: To evaluate renorrhaphy techniques and to analyze surgical outcomes in retroperitoneal laparoscopic partial nephrectomy. Methods: A retrospective study from January 2008 to December 2011 analyzed 526 patients with renal tumors in whom renorrhaphy was changed from one layer, interrupted, figure-of-eight (n = 228) suture to two layers, continuous, unknotted (n = 298) suture. All procedures were carried out by the same laparoscopic surgeon (XZ). Patient demographics, tumor characteristics, operative outcomes and perioperative renal function were compared. Results: Median follow up for one layer, interrupted, figure-of-eight suture and two layers, continuous, unknotted suture was 31 and 28 months, respectively. The two layers, continuous, unknotted suture group had shorter warm ischemia time (P = 0.021), faster removal of Jackson-Pratt drains (P = 0.029) and shorter hospital stay (P = 0.037) than the one layer, interrupted, figure-of-eight suture group. There was a trend towards a better preservation of glomerular filtration rates in the two layers, continuous, unknotted suture group (P = 0.045). In a multivariable model, the two layers, continuous, unknotted suture technique was a statistically significant independent predictor of warm ischemia time (P = 0.01), hospital stay (P = 0.001) and estimated glomerular filtration rates (P = 0.043). Conclusions: Two layers, continuous, unknotted suture renorrhaphy allows better outcomes than one layer, interrupted, figure-of-eight suture renorrhaphy in retroperitoneal laparoscopic partial nephrectomy. A longer clinical follow-up evaluation is warranted.
Key words: outcomes, partial nephrectomy, renal tumors, renorrhaphy, retroperitoneal laparoscopy.
Introduction LPN has generally been considered to be the standard for appropriate renal tumors.1–5 The approach of LPN, namely transperitoneal or retroperitoneal, is primarily based on the individual surgeon’s experience and preference, tumor location, and tumor size. Despite the relatively small space available for operating, the retroperitoneal approach offers excellent access to the renal artery, less bowel irritation, lower risk of organ injury and limited postoperative fluid in the retroperitoneum.6–8 However, regardless of the approach, the renorrhaphy technique applied is one of the key factors from a surgical standpoint that influences perioperative outcomes. Renorrhaphy is a very important technique for achieving adequate hemostasis and reconstruction of the kidney within a reasonable WIT during LPN. The most widely used renorrhaphy technique during partial nephrectomy bed is freehand laparoscopic suturing with or without adjunctive biological hemostatic agents. In a previous study, our group studied the use of an initial renorrhaphy in OLIF technique for retroperitoneal LPN.9 To date, there is another kind of notable renorrhaphy: the TLCU technique. When focusing on renorrhaphy technique options in retroperitoneal LPN, no studies comparing surgical effectiveness of OLIF and TLCU have been reported. The aim of the present study was to compare perioperative, functional, and oncological outcomes of OLIF and TLCU in patients undergoing retroperitoneal LPN.
Methods Patient selection From January 2008 to December 2011, a total of 1181 patients with organ-confined renal tumors in the Department of Urology, PLA Military Hospital of Beijing, Beijing, China, © 2014 The Japanese Urological Association
865
W WAHAFU ET AL.
(a)
(b)
(c)
(d)
(e)
(f) Fig. 1 (a) Port positioning for retroperitoneal LPN. (b) The renal artery is occluded with bulldog clamps. (c) Original OLIF technique placed over the hemostatic gauze. (d) Contemporary TLCU technique: a running suture oversewed the tumor excision bed. (e) One sliding Hem-o-lok clip secured the final throw on the renal capsule. (f) Two sutures were tied to each other after placing the last sliding Hemo-lok clip.
underwent LPN by a retroperitoneal approach. Patients treated with a transperitoneal approach (n = 68) during the same time period were excluded. All patients were assessed with either computed tomography or magnetic resonance imaging before operation. None of the patients were found to have metastatic disease. Of these patients, 567 were treated by the same laparoscopic surgeon (XZ). Patients who were missing clinical information (n = 12) or lost to follow up (n = 29) were excluded, leaving 526 patients available for analysis. These patients had undergone either type of renorrhaphy technique: 228 patients underwent OLIF, and 298 patients underwent TLCU.
Surgical technique Technique for OLIF Our renorrhaphy technique of OLIF has been previously described.9 In short, the patient was placed in the modified flank position, and three trocars were placed to complete the dissection from the retroperitoneal approach (Fig. 1a). Artery-only clamping was carried out (Fig. 1b). Intraoperative ultrasonography was mostly used to confirm the location, width and depth of the endophytic tumor. Once complete tumor resection was verified using the laparoscopic shears, the harmonic scalpel could be used to control parenchymal surface oozing and bleeding from small interlobar vessels. An interrupted figure-of-eight suture was used when the colleting system was entered. Adjunctive fibrin glue was applied, and a bolster might be omitted in select cases. The edges of the parenchyma were approximated with OLIF stitches using 0-Vicryl suture (Fig. 1c). The hilum was then unclamped and the renorrhaphy was inspected for hemostasis.
Technique for TLCU TLCU patients underwent all previously described steps up until the capsular renorrhaphy, where instead of OLIF the technique of TLCU was carried out. A 15-cm 2-0 Monocryl suture was tied to a Hem-o-lok clip at the free end and used as a running suture of the tumor excision bed to oversew larger 866
vessels as well as entries into the collecting system (Fig. 1d). Every three throws were placed in the longitudinal axis of the partial nephrectomy bed, and the suture was then gently pulled. The suture was brought through the renal capsule with the final throw and secured with one sliding Hem-o-lok clip (Fig. 1e). The renal capsule was re-approximated using a continuous, horizontal running 20-cm 0-Vicryl suture (tied to a Hem-o-lok clip the same as the first suture) with a sliding Hem-o-lok clip placed after the suture passed through the left side of capsule and readjusted the tension. After placing the last sliding Hemo-lok clip, the renal artery was unclamped and both needles were then removed from the suture. The renorrhaphy sutures were tied to each other (Fig. 1f).
Measurements Patient demographics (sex, age), clinical characteristics (BMI, ASA score, age-adjusted CCI, ECOG PS), tumor characteristics (tumor size, location, histology, pathological stage, Fuhrman grade, margin status), surgical characteristics (operative time, WIT, EBL, drain days, passing flatus days, length of hospital stay), postoperative complications (up to 30 days after surgery), oncological outcomes (recurrence rates and mortality) and renal function outcomes (sCr, BUN, eGFR) were retrospectively analyzed. Our operation time was from skin incision to closure. A further comparison of operative outcomes and renal function were carried out between the initial 50% cases and the last 50% patients in each group. The tumor was classified according to location on radiological imaging studies, when it was external to the line of the renal capsule it was considered exophytic when greater than 60%, mesophytic when 40–60% and endophytic when less than 40%.10 Postoperative complication data were collected using the modified Clavien scale.11 eGFR was calculated using the abbreviated equations of the Modification of Diet in Renal Disease for Chinese patients (in mL/min/ 1.73 m2) = 186 × sCr−1.154 × age−0.203 × 0.742 (if female) × 1.233 (if Chinese).12 We defined that the Jackson-Pratt drain could be removed when the drained volume was less than 30 mL, and patients could discharge 1 day after the removal of the JP drain. © 2014 The Japanese Urological Association
Evolving renorrhaphy technique
Follow-up and convalescence data were obtained by telephone contact.
Table 1
Patient characteristics
Variables
Statistical analysis The baseline characteristics of the OLIF and TLCU groups were compared using independent samples t-test for continuous variables. The χ2-test was used to estimate unordered categorical variables, and the Mann–Whitney U-test was used to adjust for ordinal categorical variables. For the multivariate analysis, the dependent variables as a continuous variable were evaluated using a generalized linear model. Response distribution was assumed to be normal distribution, and link function was identity. The independent variables as covariates were put into the multivariate analyzed model. As a main effect model, it did not join the interactive effects. All statistical analyses were carried out using SPSS 19.0 (SPSS, Chicago, IL, USA), and two-sided P-values
