Tailoring technique of laparoscopic partial nephrectomy to tumor characteristics

We use a tailored approach to laparoscopic partial nephrectomy based on tumor depth of penetration and proximity to the renal sinus. We evaluated differences in perioperative outcomes to determine the value of this paradigm.

The surgical approach to hilar clamping and tumor bed management during laparoscopic partial nephrectomy included no clamp or suture, clamp with no suture, and clamp and suture. The end points assessed retrospectively were differences in perioperative, pathological and complication outcomes among these groups.

Our surgical paradigm was used in 174 patients, including no clamp or suture in 36, clamp with no suture in 25, and clamp and suture in 113. Compared to the other patients those with a clamp and suture procedure were older with larger and deeper tumors that were closer to the renal sinus-collecting system and more likely to be malignant. Operative time was shortest in the no clamp or suture group and in the 2 clamp groups warm ischemia and operative times were shorter than in the no suture group. Estimated blood loss, hospital stay, surgical margins, complications and recurrences did not differ among the groups. A creatinine increase of 0.3 mg/dl or greater was seen in 33 patients (19%) following surgery, which was attributable to conversion to nephrectomy in 4, contralateral nephrectomy or partial nephrectomy in 3 and underlying medical renal disease in 1. In the remaining 25 patients no other cause was apparent except renal hilar clamping and tumor resection.

A tailored approach based on tumor location and proximity to the renal sinus-collecting system can limit operative and ischemia times, and technically simplify the procedure without adversely impacting morbidity, convalescence and oncological outcomes.