Original Research
JOURNAL OF ENDOUROLOGY Volume XX, Number XX, XXXXXX 2015 ª Mary Ann Liebert, Inc. Pp. ---–--DOI: 10.1089/end.2015.0064
The Application of ‘‘Renal Pedicle Rotation’’ Method in Retroperitoneal Laparoscopic Partial Nephrectomy for Renal Ventral Tumors Shiyu Song, MD, Hongxian Zhang, MD, Lulin Ma, MD, Yi Huang, MD, Lei Zhao, MD, Guoliang Wang, MD, Jian Lu, MD, and Shudong Zhang, MD
Abstract
Objectives: To present preliminary experience of ‘‘renal pedicle rotation’’ method in retroperitoneal laparoscopic partial nephrectomy (RLPN) for renal ventral tumors. Methods: A retrospective analysis of renal surgery database about patients undergoing RLPN was conducted. We identified 14 consecutive cases of all the surgeries from December 2013 to October 2014 with renal ventral tumors. The 14 surgeries were all in the application of renal pedicle rotation method, an intraoperative skill in which surgeons rotates the kidney on renal pedicle axis after separating renal artery and vein for a better tumor exposure. Results: A total of 14 patients underwent RLPN. All surgeries were successful without conversion to radical nephrectomy or open partial nephrectomy. The mean operative time was 171.1 – 47.2 min (range 83–246), the mean warm ischemia time was 15.9 – 9.8 min (range 7–35) and the mean estimated blood loss was 89.3 – 102.2 mL (range 10–300). Mean postoperative hospital stay was 6.2 – 1.9 days (range 4–10) and mean retroperitoneal drainage was 4.2 – 1.4 days (range 2–8). No intraoperative complications occurred. Postoperative complications developed in four patients. All patients had negative margins and pathological examination revealed 10 (71.4%) clear cell carcinomas, two (14.2%) epithelial renal angiomyolipoma, one (7.1%) papillary carcinoma and one (7.1%) nephrotuberculosis. The review of the early oncologic outcomes revealed no local recurrence and distant metastasis. Conclusion: The renal pedicle rotation method might be a feasible and safe procedure to get a better tumor exposure for incision and suture in renal ventral tumors RLPN surgeries with acceptable postoperative outcomes. hands of experienced laparoscopists due to complexity of exposing tumor and separating renal vessels and urinary collecting system.6 Generally, we define complex or difficult renal tumor locations as hilar/central tumors (renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively).7 When the tumor location is opposite to operative approach, laparoscopists face difficulties in exposing tumors and suturing. In retroperitoneal laparoscopic partial nephrectomy (RLPN), dealing with renal ventral tumor would be at risks of longer operative time (OT), longer warm ischemia time (WIT) and more estimated blood loss (EBL). Therefore, with the difficulty and potentially increased incidence of complications, some cases converse to OPN.8 According to our initial experience in the application of ‘‘renal pedicle rotation’’ method, which is an intraoperative skill in which surgeons rotated the kidney on renal pedicle axis after separating renal artery and vein to make the
Introduction
T
hrough many years of clinical studies, partial nephrectomy in the treatment of renal tumors is with enough safety and effectiveness.1 Compared with open surgery, laparoscopic partial nephrectomy (LPN) has exhibited a large growth in worldwide popularity for renal tumors with the advantages of minimal invasion, quicker recovery and less analgesic drug application.2,3 Traditional open partial nephrectomy (OPN) provides excellent oncological and renal functional outcomes at 10 years and beyond.4 Recently, the application of LPN has increased in the last decade with a trend to emerge as an alternative to OPN with durable renal function and oncology outcomes.5 To date, most LPN series have focused on establishing efficacy for the treatment of easily accessible peripheral tumors. But difficult tumor locations have been previously considered as a relative contraindication to LPN even in the
Department of Urology, Peking University Third Hospital, Beijing, China.
1
2
tumor exposed clearly, it is a feasible and safe procedure for renal ventral tumors. Materials and Methods
A retrospective review of renal neoplasm surgery database about patients who had undergone RLPN was conducted. We identified 14 consecutive cases of all the surgeries from December 2013 to October 2014 who had renal ventral tumors as research samples. Among these 14 patients of chosen cases, one patient had undergone right kidney partial nephrectomy due to renal clear cell carcinoma in retroperitoneal partial nephrectomy previously. No solitary kidney was present. Seven patients were male (50%) and seven were female (50%) and mean age was 62.1 – 11.3(range 46–83), the body mass index was 24.4 – 1.6 kg/m2 (range 20.7–26.3), six patients had tumors in left kidney (42.9%) and eight patients had tumors in right kidney (57.1%). Routine preoperative evaluations included a complete record of medical history, physical examination, laboratory investigation, computerized tomography and magnetic resonance imaging of the urinary system. Specifically, renogram is an essential examination for evaluating bilateral kidney function. All of the tumors were confirmed in the ventral location by computerized tomography preoperatively and then evaluated with the R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) nephrometry scoring system.9 Preoperative imaging was used to obtain tumor characteristics, including tumor size, location and tumor complexity on the basis of R.E.N.A.L. nephrometry scoring system. Charlson comorbidity index and the routine laboratory investigations, including hemoglobin (Hb) and serum creatinine (SCr) levels, were consequential to evaluate surgical results with comparison between preoperative and postoperative conditions. The baseline demographics and perioperative outcomes were based on a retrospective data collected from all 14 patients, shown in Table 1. The R.E.N.A.L. nephrometry scores were generated and verified by two residents, one surgeon and two physicians familiar with the R.E.N.A.L. nephrometry scoring system. RLPN was completed using a standard three-port technique by experienced surgeons as previously described. Routinely, the patient was positioned in the full lateral decubitus position with overextension. A 1.5 cm skin incision was initially made at the cross point of the line 2 cm above the psoas major and the costal margin. A handmade balloon dilating device was then placed to create a retroperitoneal space, and the first 13-mm port was inserted into the retroperitoneal space at a 30 angle to the perpendicular line. After that, a pressure of pneumoperitoneum of 12 mm Hg was achieved. The tumors were in ventral location of among all targets and the effect of exposure was not satisfying enough to operate (Fig. 1). After finishing separating Gerota’s fascia and perirenal fat along the surface of kidney for making it skeletonized, we exposed renal artery and vein. Then, the kidney was delicately rotated a suitable angle on renal pedicle axis (Fig. 2) to make appropriate surgery field and for an optimal straight tumor exposure on renal pedicle rotation method (Fig. 3). Laparoscopic bulldog clamps were applied before renal tumor extirpation and then mark the time for WIT. Then we excised the renal tumor and kidney tissue
SONG ET AL.
Table 1. Patients Baseline Demographics and Presentations Gender (%) Male 7 (50%) Female 7 (50%) Age (years) 62.1 – 11.3 (46–83) BMI (kg/m2) 24.4 – 1.6 (20.7–26.3) Tumor location (%) Left 6 (42.9%) Right 8 (57.1%) Charlson comorbidity index, 1.4 – 1.9 (0–6) age-weighted Preoperative GFR (mL/min) 92.6 – 27.0 (49.6–166.4) Preoperative SCr (mg/dL) 0.83 – 0.17 (0.54–1.22) Preoperative Hb (g/L) 130.7 – 11.9 (114–154) Preoperative tumor size (cm) 3.1 – 1.0 (1.4–5.2) R.E.N.A.L. nephrometry scores (%) 4–6 8 (57.1%) 7–9 5 (35.7%) 10–12 1 (7.1%) (R)adius (diameter) (%) 1 13 (92.9%) 2 1 (7.1%) 3 0 (E)xophytic/endophytic (%) 1 11 (78.6%) 2 3 (21.4%) 3 0 (N)earness of tumor to collecting system or sinus (%) 1 6 (42.9%) 2 5 (35.7%) 3 3 (21.4%) (A)nterior or (P)osterior or (x) (%) A 14 (100%) P 0 x 0 (L)ocation relative to polar lines (%) 1 5 (35.7%) 2 7 (50.0%) 3 2 (14.3%) ‘‘H’’ilar location (abutting main artery or vein) (%) Hilar 5 (35.7%) Nonhilar 9 (64.3%) BMI = body mass index; GFR = glomerular filtration rate; Hb = hemoglobin; R.E.N.A.L. = radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines; SCr = serum creatinine.
using the laparoscopic scissors with a distance of 0.1–0.5 cm from the tumor margin. In most cases, the use of arterial clamping provided a bloodless incision of the renal parenchyma and a very safe delineation of the plane between tumor and surrounding tissue. In one case in which the feeding blood vessels entered the tumor directly from the main renal artery, we clipped the branch. With deep incision and subsequent collection system damaged, we continuously sutured collection system using 3-0 absorbable suture and then continuously sutured renal parenchyma with 2-0 absorbable suture. After removing the laparoscopic bulldog clamps to restore blood flow, we restored the original location of the kidney by rotating the kidney on renal pedicle axis opposite
‘‘RENAL PEDICLE ROTATION’’ METHOD IN LPN
FIG. 1. The tumor (arrow points) was in ventral location and the exposure was not satisfying enough. to the previous clockwise. All patients were treated without ureteral stent. OT, WIO and EBL were recorded. Postoperatively, the specimen was sent for pathological analysis including tumor histology, TNM stage, and margin status. The levels of Hb and SCr were remeasured. Postoperative hospital stay, retroperitoneal drainage and postoperative complications were recorded. With a mean follow-up for 8.1 – 3.0 months (range 3–13), early oncologic outcomes, local recurrence and distant metastasis were also analyzed. Patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. Results
All 14 procedures were carried out successfully and consecutively. Of these procedures, no conversion to OPN or radical nephrectomy occurred. No patients needed blood transfusion during operations. The mean OT was 171.1 – 47.2 min (range 83–246), and the mean WIT was 15.9 –
3
FIG. 3.
The tumor (arrow points) was exposed clearly.
9.8 min (range 7–35). Of all patients, preoperative (0.83 – 0.17 mg/dL) and postoperative (0.86 – 0.18 mg/dL) SCr had a nonsignificant difference ( p = 0.24 > 0.05). All of the postoperative SCr levels were within normal limits, and no patient required dialysis due to renal insufficiency. The mean EBL was 89.3 – 102.2 mL (range 10–300). Even though there was a significant difference ( p = 0.0007 < 0.05) between preoperative (130.7 – 11.9 g/L) and postoperative (110.0 – 8.7 g/L) Hb, no patient had abnormal Hb or only short-term mild anemia and no transfusion were required after surgeries. Mean postoperative hospital stay was 6.2 – 1.9 days (range 4–10) and mean retroperitoneal drainage was 4.2 – 1.4 days (range 2–8). Four postoperative complications occurred, including fever in three (21.4%), ileus in one (7.1%). No urinary tract infection, hemorrhage, perirenal fluid collection or urine leak occurred. The four patients recovered with active surveillance and treatment. Detailed patients’ intraoperative and postoperative outcomes are shown in Table 2. All patients had negative margins on the final pathologic examination. And tumors in 14 cases were stage T1 tumors within proportion of T1a and T1b for 13 (92.9%) and one (7.1%), respectively. No lymphatic metastasis or distant metastasis were discovered. Pathological examination revealed 10 (71.4%) renal clear cell carcinomas, two (14.2%) epithelial renal angiomyolipoma, one (7.1%) renal papillary carcinoma and one (7.1%) nephrotuberculosis. Pathological renal Fuhrman grade provided that 1 grade in one (7.1%), 2 grade in 10 (71.4%) and uncertain in three (21.4%). Eleven of 14 (78.6%), were malignant. With a mean follow-up for 8.1 – 3.0 months (range 3–13), no local recurrence and metastasis occurred. The 14 patients’ pathological characteristics and oncological outcomes are shown individually in Table 3. Comment
FIG. 2. ‘‘Renal pedicle rotation’’ method, rotating the kidney on renal pedicle axis delicately.
As recent guidelines have mentioned, active surveillance, surgical excision, thermal ablation are three viable treatment strategies for appropriately selected patients with a clinical stage T1 renal mass.10,11 Traditional renal tumor guideline suggests that the conventional standard of treatment is surgical excision in open surgery, especially partial nephrectomy.12,13
4
SONG ET AL.
Table 2. Patients’ Intraoperative and Postoperative Outcomes Individually Pre-op. Post-op. Retroperitoneal Postoperative OT WIT EBL Pre-op. Post-op. SCr SCr drainage hospital stay Patient No. (min) (min) (mL) Hb (g/L) Hb (g/L) (mg/dL) (mg/dL) (days) (days) Complications 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mean SD
211 190 151 169 109 181 83 213 165 169 239 246 124 145 171.1 47.2
22 16 9 20 20 17 6 11 8 35 35 7 9 7 15.9 9.8
100 300 300 20 10 200 10 80 50 20 20 50 60 30 89.3 102.2
145 130 141 117 120 131 154 142 132 120 114 136 129 119 130.7 11.9
100 107 93 110 114 66 135 138 126 109 91 126 108 106 110.0 18.7
0.93 0.69 0.54 1.22 0.77 0.71 0.89 0.85 0.95 0.78 0.94 0.86 0.63 0.85 0.83 0.17
0.95 0.81 0.53 1.18 0.75 0.67 0.84 0.87 0.87 0.98 1.10 0.87 0.61 0.98 0.86 0.18
3 4 5 5 4 5 2 4 3 5 8 4 4 3 4.2 1.4
5 8 9 8 5 6 4 6 4 7 10 5 6 4 6.2 1.9
No Ileus Fever No No Fever No No No No Fever No No No
EBL = estimated blood loss; OT = operative time; Post-op. = postoperative; Pre-op. = preoperative; SD = standard deviation; WIT = warm ischemia time.
However, evidence is accumulating regarding the potential benefits of LPN, although it was initially used primarily in small and exophytic lesions.14 LPN has compared favorably with OPN in a number of recently published studies and LPN has been shown to be an accepted, safe and feasible treatment option for small renal masses (
JOURNAL OF ENDOUROLOGY Volume XX, Number XX, XXXXXX 2015 ª Mary Ann Liebert, Inc. Pp. ---–--DOI: 10.1089/end.2015.0064
The Application of ‘‘Renal Pedicle Rotation’’ Method in Retroperitoneal Laparoscopic Partial Nephrectomy for Renal Ventral Tumors Shiyu Song, MD, Hongxian Zhang, MD, Lulin Ma, MD, Yi Huang, MD, Lei Zhao, MD, Guoliang Wang, MD, Jian Lu, MD, and Shudong Zhang, MD
Abstract
Objectives: To present preliminary experience of ‘‘renal pedicle rotation’’ method in retroperitoneal laparoscopic partial nephrectomy (RLPN) for renal ventral tumors. Methods: A retrospective analysis of renal surgery database about patients undergoing RLPN was conducted. We identified 14 consecutive cases of all the surgeries from December 2013 to October 2014 with renal ventral tumors. The 14 surgeries were all in the application of renal pedicle rotation method, an intraoperative skill in which surgeons rotates the kidney on renal pedicle axis after separating renal artery and vein for a better tumor exposure. Results: A total of 14 patients underwent RLPN. All surgeries were successful without conversion to radical nephrectomy or open partial nephrectomy. The mean operative time was 171.1 – 47.2 min (range 83–246), the mean warm ischemia time was 15.9 – 9.8 min (range 7–35) and the mean estimated blood loss was 89.3 – 102.2 mL (range 10–300). Mean postoperative hospital stay was 6.2 – 1.9 days (range 4–10) and mean retroperitoneal drainage was 4.2 – 1.4 days (range 2–8). No intraoperative complications occurred. Postoperative complications developed in four patients. All patients had negative margins and pathological examination revealed 10 (71.4%) clear cell carcinomas, two (14.2%) epithelial renal angiomyolipoma, one (7.1%) papillary carcinoma and one (7.1%) nephrotuberculosis. The review of the early oncologic outcomes revealed no local recurrence and distant metastasis. Conclusion: The renal pedicle rotation method might be a feasible and safe procedure to get a better tumor exposure for incision and suture in renal ventral tumors RLPN surgeries with acceptable postoperative outcomes. hands of experienced laparoscopists due to complexity of exposing tumor and separating renal vessels and urinary collecting system.6 Generally, we define complex or difficult renal tumor locations as hilar/central tumors (renal cortical tumors in direct physical contact with the renal artery, vein, or both, as identified on preoperative imaging and confirmed intraoperatively).7 When the tumor location is opposite to operative approach, laparoscopists face difficulties in exposing tumors and suturing. In retroperitoneal laparoscopic partial nephrectomy (RLPN), dealing with renal ventral tumor would be at risks of longer operative time (OT), longer warm ischemia time (WIT) and more estimated blood loss (EBL). Therefore, with the difficulty and potentially increased incidence of complications, some cases converse to OPN.8 According to our initial experience in the application of ‘‘renal pedicle rotation’’ method, which is an intraoperative skill in which surgeons rotated the kidney on renal pedicle axis after separating renal artery and vein to make the
Introduction
T
hrough many years of clinical studies, partial nephrectomy in the treatment of renal tumors is with enough safety and effectiveness.1 Compared with open surgery, laparoscopic partial nephrectomy (LPN) has exhibited a large growth in worldwide popularity for renal tumors with the advantages of minimal invasion, quicker recovery and less analgesic drug application.2,3 Traditional open partial nephrectomy (OPN) provides excellent oncological and renal functional outcomes at 10 years and beyond.4 Recently, the application of LPN has increased in the last decade with a trend to emerge as an alternative to OPN with durable renal function and oncology outcomes.5 To date, most LPN series have focused on establishing efficacy for the treatment of easily accessible peripheral tumors. But difficult tumor locations have been previously considered as a relative contraindication to LPN even in the
Department of Urology, Peking University Third Hospital, Beijing, China.
1
2
tumor exposed clearly, it is a feasible and safe procedure for renal ventral tumors. Materials and Methods
A retrospective review of renal neoplasm surgery database about patients who had undergone RLPN was conducted. We identified 14 consecutive cases of all the surgeries from December 2013 to October 2014 who had renal ventral tumors as research samples. Among these 14 patients of chosen cases, one patient had undergone right kidney partial nephrectomy due to renal clear cell carcinoma in retroperitoneal partial nephrectomy previously. No solitary kidney was present. Seven patients were male (50%) and seven were female (50%) and mean age was 62.1 – 11.3(range 46–83), the body mass index was 24.4 – 1.6 kg/m2 (range 20.7–26.3), six patients had tumors in left kidney (42.9%) and eight patients had tumors in right kidney (57.1%). Routine preoperative evaluations included a complete record of medical history, physical examination, laboratory investigation, computerized tomography and magnetic resonance imaging of the urinary system. Specifically, renogram is an essential examination for evaluating bilateral kidney function. All of the tumors were confirmed in the ventral location by computerized tomography preoperatively and then evaluated with the R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) nephrometry scoring system.9 Preoperative imaging was used to obtain tumor characteristics, including tumor size, location and tumor complexity on the basis of R.E.N.A.L. nephrometry scoring system. Charlson comorbidity index and the routine laboratory investigations, including hemoglobin (Hb) and serum creatinine (SCr) levels, were consequential to evaluate surgical results with comparison between preoperative and postoperative conditions. The baseline demographics and perioperative outcomes were based on a retrospective data collected from all 14 patients, shown in Table 1. The R.E.N.A.L. nephrometry scores were generated and verified by two residents, one surgeon and two physicians familiar with the R.E.N.A.L. nephrometry scoring system. RLPN was completed using a standard three-port technique by experienced surgeons as previously described. Routinely, the patient was positioned in the full lateral decubitus position with overextension. A 1.5 cm skin incision was initially made at the cross point of the line 2 cm above the psoas major and the costal margin. A handmade balloon dilating device was then placed to create a retroperitoneal space, and the first 13-mm port was inserted into the retroperitoneal space at a 30 angle to the perpendicular line. After that, a pressure of pneumoperitoneum of 12 mm Hg was achieved. The tumors were in ventral location of among all targets and the effect of exposure was not satisfying enough to operate (Fig. 1). After finishing separating Gerota’s fascia and perirenal fat along the surface of kidney for making it skeletonized, we exposed renal artery and vein. Then, the kidney was delicately rotated a suitable angle on renal pedicle axis (Fig. 2) to make appropriate surgery field and for an optimal straight tumor exposure on renal pedicle rotation method (Fig. 3). Laparoscopic bulldog clamps were applied before renal tumor extirpation and then mark the time for WIT. Then we excised the renal tumor and kidney tissue
SONG ET AL.
Table 1. Patients Baseline Demographics and Presentations Gender (%) Male 7 (50%) Female 7 (50%) Age (years) 62.1 – 11.3 (46–83) BMI (kg/m2) 24.4 – 1.6 (20.7–26.3) Tumor location (%) Left 6 (42.9%) Right 8 (57.1%) Charlson comorbidity index, 1.4 – 1.9 (0–6) age-weighted Preoperative GFR (mL/min) 92.6 – 27.0 (49.6–166.4) Preoperative SCr (mg/dL) 0.83 – 0.17 (0.54–1.22) Preoperative Hb (g/L) 130.7 – 11.9 (114–154) Preoperative tumor size (cm) 3.1 – 1.0 (1.4–5.2) R.E.N.A.L. nephrometry scores (%) 4–6 8 (57.1%) 7–9 5 (35.7%) 10–12 1 (7.1%) (R)adius (diameter) (%) 1 13 (92.9%) 2 1 (7.1%) 3 0 (E)xophytic/endophytic (%) 1 11 (78.6%) 2 3 (21.4%) 3 0 (N)earness of tumor to collecting system or sinus (%) 1 6 (42.9%) 2 5 (35.7%) 3 3 (21.4%) (A)nterior or (P)osterior or (x) (%) A 14 (100%) P 0 x 0 (L)ocation relative to polar lines (%) 1 5 (35.7%) 2 7 (50.0%) 3 2 (14.3%) ‘‘H’’ilar location (abutting main artery or vein) (%) Hilar 5 (35.7%) Nonhilar 9 (64.3%) BMI = body mass index; GFR = glomerular filtration rate; Hb = hemoglobin; R.E.N.A.L. = radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines; SCr = serum creatinine.
using the laparoscopic scissors with a distance of 0.1–0.5 cm from the tumor margin. In most cases, the use of arterial clamping provided a bloodless incision of the renal parenchyma and a very safe delineation of the plane between tumor and surrounding tissue. In one case in which the feeding blood vessels entered the tumor directly from the main renal artery, we clipped the branch. With deep incision and subsequent collection system damaged, we continuously sutured collection system using 3-0 absorbable suture and then continuously sutured renal parenchyma with 2-0 absorbable suture. After removing the laparoscopic bulldog clamps to restore blood flow, we restored the original location of the kidney by rotating the kidney on renal pedicle axis opposite
‘‘RENAL PEDICLE ROTATION’’ METHOD IN LPN
FIG. 1. The tumor (arrow points) was in ventral location and the exposure was not satisfying enough. to the previous clockwise. All patients were treated without ureteral stent. OT, WIO and EBL were recorded. Postoperatively, the specimen was sent for pathological analysis including tumor histology, TNM stage, and margin status. The levels of Hb and SCr were remeasured. Postoperative hospital stay, retroperitoneal drainage and postoperative complications were recorded. With a mean follow-up for 8.1 – 3.0 months (range 3–13), early oncologic outcomes, local recurrence and distant metastasis were also analyzed. Patient baseline demographics, perioperative outcomes and pathological characteristics were recorded based on a retrospective data collection and telephone interview. Results
All 14 procedures were carried out successfully and consecutively. Of these procedures, no conversion to OPN or radical nephrectomy occurred. No patients needed blood transfusion during operations. The mean OT was 171.1 – 47.2 min (range 83–246), and the mean WIT was 15.9 –
3
FIG. 3.
The tumor (arrow points) was exposed clearly.
9.8 min (range 7–35). Of all patients, preoperative (0.83 – 0.17 mg/dL) and postoperative (0.86 – 0.18 mg/dL) SCr had a nonsignificant difference ( p = 0.24 > 0.05). All of the postoperative SCr levels were within normal limits, and no patient required dialysis due to renal insufficiency. The mean EBL was 89.3 – 102.2 mL (range 10–300). Even though there was a significant difference ( p = 0.0007 < 0.05) between preoperative (130.7 – 11.9 g/L) and postoperative (110.0 – 8.7 g/L) Hb, no patient had abnormal Hb or only short-term mild anemia and no transfusion were required after surgeries. Mean postoperative hospital stay was 6.2 – 1.9 days (range 4–10) and mean retroperitoneal drainage was 4.2 – 1.4 days (range 2–8). Four postoperative complications occurred, including fever in three (21.4%), ileus in one (7.1%). No urinary tract infection, hemorrhage, perirenal fluid collection or urine leak occurred. The four patients recovered with active surveillance and treatment. Detailed patients’ intraoperative and postoperative outcomes are shown in Table 2. All patients had negative margins on the final pathologic examination. And tumors in 14 cases were stage T1 tumors within proportion of T1a and T1b for 13 (92.9%) and one (7.1%), respectively. No lymphatic metastasis or distant metastasis were discovered. Pathological examination revealed 10 (71.4%) renal clear cell carcinomas, two (14.2%) epithelial renal angiomyolipoma, one (7.1%) renal papillary carcinoma and one (7.1%) nephrotuberculosis. Pathological renal Fuhrman grade provided that 1 grade in one (7.1%), 2 grade in 10 (71.4%) and uncertain in three (21.4%). Eleven of 14 (78.6%), were malignant. With a mean follow-up for 8.1 – 3.0 months (range 3–13), no local recurrence and metastasis occurred. The 14 patients’ pathological characteristics and oncological outcomes are shown individually in Table 3. Comment
FIG. 2. ‘‘Renal pedicle rotation’’ method, rotating the kidney on renal pedicle axis delicately.
As recent guidelines have mentioned, active surveillance, surgical excision, thermal ablation are three viable treatment strategies for appropriately selected patients with a clinical stage T1 renal mass.10,11 Traditional renal tumor guideline suggests that the conventional standard of treatment is surgical excision in open surgery, especially partial nephrectomy.12,13
4
SONG ET AL.
Table 2. Patients’ Intraoperative and Postoperative Outcomes Individually Pre-op. Post-op. Retroperitoneal Postoperative OT WIT EBL Pre-op. Post-op. SCr SCr drainage hospital stay Patient No. (min) (min) (mL) Hb (g/L) Hb (g/L) (mg/dL) (mg/dL) (days) (days) Complications 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mean SD
211 190 151 169 109 181 83 213 165 169 239 246 124 145 171.1 47.2
22 16 9 20 20 17 6 11 8 35 35 7 9 7 15.9 9.8
100 300 300 20 10 200 10 80 50 20 20 50 60 30 89.3 102.2
145 130 141 117 120 131 154 142 132 120 114 136 129 119 130.7 11.9
100 107 93 110 114 66 135 138 126 109 91 126 108 106 110.0 18.7
0.93 0.69 0.54 1.22 0.77 0.71 0.89 0.85 0.95 0.78 0.94 0.86 0.63 0.85 0.83 0.17
0.95 0.81 0.53 1.18 0.75 0.67 0.84 0.87 0.87 0.98 1.10 0.87 0.61 0.98 0.86 0.18
3 4 5 5 4 5 2 4 3 5 8 4 4 3 4.2 1.4
5 8 9 8 5 6 4 6 4 7 10 5 6 4 6.2 1.9
No Ileus Fever No No Fever No No No No Fever No No No
EBL = estimated blood loss; OT = operative time; Post-op. = postoperative; Pre-op. = preoperative; SD = standard deviation; WIT = warm ischemia time.
However, evidence is accumulating regarding the potential benefits of LPN, although it was initially used primarily in small and exophytic lesions.14 LPN has compared favorably with OPN in a number of recently published studies and LPN has been shown to be an accepted, safe and feasible treatment option for small renal masses (
