'Zero ischaemia', sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Ischaemic injury produced by hilar clamping during partial nephrectomy is the main determinant of renal function loss. The exact measurement of ipsilateral renal function loss can be underestimated by serum creatinine levels and estimated GFR. Few reports of unclamped laparoscopic partial nephrectomy (LPN) are available in the literature, although this technique shows promising results. The present study includes a series of patients with the longest follow-up of LPN without hilar clamping and without parenchymal reconstruction. Excellent cancer control and optimum renal functional preservation suggest that this technique could be performed in selected patients, i.e. those with small and peripheral tumours (also classified as low nephrometry score tumours).

To describe the technique and report the results of 'zero ischaemia', sutureless laparoscopic partial nephrectomy (LPN) for renal tumours with a low nephrometry score.

Between August 2003 and January 2010, data from 101 consecutive patients who underwent 'zero ischaemia', sutureless LPN were collected in a prospectively maintained database. Inclusion criteria were tumour size ≤ 4 cm, predominant exophytic growth and intraparenchymal depth ≤ 1.5 cm, with a minimum distance of 5 mm from the urinary collecting system. Hilar vessels were not isolated, tumour dissection was performed with 10-mm LigaSure(TM) (Covidien, Boulder, CO, USA) and haemostasis was performed with coagulation and biological haemostatic agents without reconstructing the renal parenchyma. Clinical, perioperative and follow-up data were collected prospectively, and modifications of functional outcome variables were analysed using the paired Wilcoxon test.

The median (range) tumour size was 2.4 (1.5-4) cm, and the median (range) intraparenchymal depth was 0.7 (0.4-1.4) cm. Hilar clamping was not necessary in any patient, and suture was performed in four patients to ensure complete haemostasis. The median (range) operation duration was 60 (45-160) min, and median (range) intraoperative blood loss was 100 (20-240) mL. Postoperative complications included fever (n= 4), low urinary output (n= 3) and haematoma, which was treated conservatively (n= 2). The median (range) hospital stay was 3 (2-5) days. The pathologist reported 30 benign tumours and renal cell carcinoma in 71 cases (pT1a in 69 patients, and pT1b in two patients). At a median follow-up of 57 months, one patient underwent radical nephrectomy for ipsilateral recurrence. The 1-year median (range) decrease of split renal function at renal scintigraphy was 1 (0-5) %.

Zero ischaemia LPN is a reasonable approach to treating small and peripheral tumours, and a sutureless procedure is feasible in most cases. This technique has a low complication rate and provides excellent functional outcome without impairing oncological results.