Secure Reconstruction Technique after Partial Nephrectomy
Irrespective of Tumor Size and Location
Dong Soo Park, Woong Ki Jang
Department of Urology, College of Medicine, Pochon CHA University, Bundang CHA Hospital, Sungnam, Korea
ABSTRACT
Introduction: Nephron-sparing surgery for large renal masses is not considered a safe procedure because of high
com-SOLFDWLRQUDWH:HSUHVHQWRXUH[SHULHQFHXVLQJH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH*RUH7H[®) and Hem-O-Lok®:HFN® &OLSDVKHPRVWDWLFDJHQWVGXULQJRSHQSDUWLDOQHSKUHFWRP\231WRSHUIRUPQHSKURQVSDULQJVXUJHU\IRUODUJHUHQDO
masses.
Materials and Methods: 6L[W\SDWLHQWVXQGHUZHQW231IRUVXVSLFLRXVUHQDOFHOOFDUFLQRPDV7KLUW\IRXUSDWLHQWVZLWK
WXPRUVFPLQVL]HXQGHUZHQW231ZLWK*RUH7H[®DORQHJURXS&OLQLFDOGDWDIURPDFRPSXWHUL]HGGDWDEDVH ZHUHUHYLHZHGDQGFRPSDUHGWRDFRQWHPSRUDU\JURXSRISDWLHQWVZLWKWXPRUV FP LQ VL]H ZKR XQGHUZHQW 231 FP LQ VL]H ZKR XQGHUZHQW 231FPLQVL]HZKRXQGHUZHQW231 ZLWK*RUH7H[® and Hem-O-Lok®JURXS
Results:7KHPHDQSDWLHQWDJHZDV\HDUVUDQJH\HDUVDQGWKHPHDQGXUDWLRQRIIROORZXSZDVPRQWKV
UDQJHPRQWKV7KHPHDQFROGLVFKHPLFWLPHVZHUHPLQXWHVUDQJHPLQXWHVDQGPLQXWHVUDQJH PLQXWHVUHVSHFWLYHO\LQJURXSDQG7KHWXPRUVL]HVLQJURXSVDQGZHUHFPDQGFP UHVSHFWLYHO\1RPDMRUFRPSOLFDWLRQVVXFKDVXULQHOHDNDJHRUGHOD\HGEOHHGLQJZHUHQRWHGLQHLWKHUJURXS
Conclusions:1HSKURQVSDULQJVXUJHU\XVLQJ*RUH7H[®DORQHRUD*RUH7H[® and Hem-O-Lok® combination was safe ZLWKRXWKLJKSULFHGKHPRVWDWLFDJHQWVEHFDXVHWKHWHQVLOHVWUHQJWKZDVVXI¿FLHQWWRPDLQWDLQ¿UPQHVVLQWKHUHSDLUHG SDUHQFK\PD,QDGGLWLRQWKHSURFHGXUHLVHDV\WRSHUIRUPDQGWDNHVOHVVWLPHWRFRPSOHWH)XUWKHUPRUHPDMRUFRPSOL
-FDWLRQVUHFXUUHQFHDQGLPSDLUHGUHQDOIXQFWLRQGLGQRWRFFXUZLWKWKLVSURFHGXUH
Key words: carcinoma, renal cell; nephrectomy; partial; surgical technique Int Braz J Urol. 2009; 35: 416-26
INTRODUCTION
6LQFHSDUWLDOQHSKUHFWRP\ZDV¿UVWSHUIRUPHG IRUUHQDOPDOLJQDQF\LQUHQDOFDQFHUVXUJHU\
has evolved in recent years with a trend toward paren-chymal-sparing and minimally invasive approaches.
$VDUHVXOWSDUWLDOQHSKUHFWRP\LVUHJDUGHGDVDFRP -mon and appropriate treatment for patients with small
UHQDOWXPRUVHYHQLQSDWLHQWVZLWKDQRUPDOFRQWUDODW
-HUDONLGQH\3DUWLDOQHSKUHFWRP\LVWHFKQLFDOO\PRUH FKDOOHQJLQJWKDQUDGLFDOQHSKUHFWRP\WKHUHIRUHLW
requires proper techniques. Despite various surgical techniques to prevent postoperative adverse events
DIWHUQHSKURQVSDULQJVXUJHU\PRVWODUJHVHULHVKDYH UHSRUWHGRISHUVLVWHQWXULQHOHDNRIGL
-DO\VLVDQGRIDFXWHDQGGHOD\HGEOHHGLQJ 7KHVHUHODWLYHO\KLJKFRPSOLFDWLRQUDWHVRISDUWLDO
nephrectomy require further special secure techniques to prevent adverse events that should be comfortable to both surgeons and patients. Secure reconstruction technique is particularly needed in high risk patient
surgeons have become more comfortable with the
WHFKQLTXHRISDUWLDOQHSKUHFWRP\UHQDOFDQFHUVXUJHU\ KDVDGYDQFHGGXULQJWKHHUDRIODSDURVFRS\0RUHRYHU
improved renal imaging and the increased detection of small incidental masses have allowed widespread application of laparoscopy in renal cancer surgery.
+RZHYHUODSDURVFRSLFSDUWLDOQHSKUHFWRP\/31 FDQQRWEHZLGHO\SHUIRUPHGGXHWRGLI¿FXOW\LQRE
-WDLQLQJUHQDOSDUHQFK\PDOKHPRVWDVLVDQGDFKLHYLQJ
satisfactory caliceal and renal parenchymal repair.
,QIDFWLIWKHGHIHFWLVWRRODUJHWREHUHSDLUHGRSHQ SDUWLDOQHSKUHFWRP\231LVDOVRGLI¿FXOWWRSHUIRUP GXHWRWKHH[FHVVLYHWHQVLOHIRUFHLQYROYHGZKLFK GHVWUR\VWKHUHPDLQLQJUHQDOSDUHQFK\PD7KHSRZHU
of cinching the suture down on the renal parenchyma is limited in traditional methods of closing the paren-chymal defect because of the “cheese slicing” effect of
NQRWW\LQJ7RRYHUFRPHWKLVSUREOHPSLRQHHUVKDYH
developed several techniques to enhance coaptation strength using exogenous material or clip. Lapra-ty or weck clip are currently used. Clip should be absorb-able when it is used to over seal collecting system
+HUHLQZHSUHVHQWRXUH[SHULHQFHSHUIRUPLQJ DUHFRQVWUXFWLRQWHFKQLTXHZLWK231UHJDUGOHVVRI
the size and location of the defect.
MATERIALS AND METHODS
Retrospective data analysis was performed under the approval of the Institutional Review
%RDUG%HWZHHQ-DQXDU\DQG'HFHPEHU SDWLHQWVXQGHUZHQW231IRUVXVSLFLRXVUHQDOFHOO FDUFLQRPDV7ZR VLPLODU EXW GLIIHUHQW WHFKQLTXHV ZHUHXWLOL]HGSDWLHQWVZLWKWXPRUVFPLQVL]H XQGHUZHQW231ZLWKH[SDQGHGSRO\WHWUDÀXRURHWK\O
-HQH*RUH7H[®) alone to bolster closure of the renal
SDUHQFK\PDJURXSZKLOHWKHRWKHUSDWLHQWV ZLWKWXPRUV FP LQ VL]H XQGHUZHQW 231 ZLWK FP LQ VL]H XQGHUZHQW 231 ZLWKFPLQVL]HXQGHUZHQW231ZLWK DFRPELQDWLRQRIH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH
and Hem-O-Lok® JURXS $OO SURFHGXUHV ZHUH
SHUIRUPHGE\RQHVWDIIVXUJHRQ'633UHRSHUDWLYHO\ DOOSDWLHQWVKDGVSLUDOFRPSXWHGWRPRJUDSK\&7
and blood sampling for the serum creatinine level. All patients also had repeat blood sampling to obtain
DSRVWRSHUDWLYHVHUXPFUHDWLQLQHOHYHODWWKHPRQWK IROORZXSHYDOXDWLRQVSLUDO&7ZDVSHUIRUPHGDWWKH
RUPRQWKIROORZXSHYDOXDWLRQWRLGHQWLI\DQ\
delayed complications.
*URXS([SDQGHGSRO\WHWUDÀXRURHWK\OHQH
alone. After exposing the renal tumor with the
over-O\LQJIDWDQGVXUURXQGLQJQRUPDOSDUHQFK\PDUHQDO
artery and/or vein are clamped to reduce bleeding and renal tissue turgor in all cases. It is especially helpful when repairing renal parenchyma after resecting large or embedded tumors. Ice slushing around the kidney
LVSHUIRUPHGLQDOOFDVHV7KHQWKHUHQDOWXPRUZDV UHVHFWHGZLWKDFPRUDGHTXDWHDYDLODEOHPDUJLQDQG WKHUHVHFWLRQPDUJLQZHUHFRQ¿UPHGEDVHGRQIUR]HQ VHFWLRQDQDO\VLV)LUVWWKHH[SRVHGDUFXDWHDUWHULHV
and opened collecting system were repaired with
DEVRUEDEOHVXWXUHPDWHULDO7KHUHPDLQLQJUHQDO SDUHQFK\PDZDVDSSUR[LPDWHGZLWKDEVRUEDEOH VXWXUHZLWKH[SDQGHGSRO\WHWUDÀXRURHWK\OHQHXVLQJ D YHUWLFDO PDWWUHVV VXWXUH PHWKRG7KH H[SDQGHG SRO\WHWUDÀXRURHWK\OHQHZDVIDVKLRQHGLQWRWZRVWULSV [FPLQVL]HHDFKDQGSUHSDUHGIRUXVH7KH
needle was passed through one piece of the expanded
SRO\WHWUDÀXRURHWK\OHQH DQG WKH UHQDO SDUHQFK\PD
in turn. After passing through the opposing renal
SDUHQFK\PD WKH QHHGOH ZDV SDVVHG WKURXJK WKH RWKHUSLHFHRIH[SDQGHGSRO\WHWUDÀXRURHWK\OHQHLQ DQRXWZDUGGLUHFWLRQ)RUWKHYHUWLFDOPDWWUHVVVXWXUH PHWKRGWKHQHHGOHZDVSDVVHGWKURXJKWKHH[SDQGHG SRO\WHWUDÀXRURHWK\OHQH DJDLQ DQG UHWXUQHG WR WKH RSSRVLQJVLGHLQWKHVDPHPDQQHU7KHQWKHVXWXUH PDWHULDO ZDV WLJKWHQHG EULQJLQJ WKH SDUHQFK\PD
together. Before cinching both sides of the resection
PDUJLQ R[LGL]HG FHOOXORVH 6XUJLFHO®) was often
used for plugging excessive defects after controlling
DOOEOHHGLQJ7KHSURFHGXUHZDVFRPSOHWHGDIWHUWKH VXUJHRQUHOHDVHGWKHFODPSLQJDQGYHUL¿HGQRIXUWKHU EOHHGLQJ)LJXUH
*URXS&RPELQDWLRQRIH[SDQGHGSRO\WHW
-UDÀXRURHWK\OHQHDQG+HP2/RN®. - After resection
RIDODUJHUHQDOWXPRUWKHH[SRVHGYHVVHOVDQGRSHQHG FROOHFWLQJV\VWHPZHUHUHSDLUHGZLWKDEVRUEDEOH VXWXUHPDWHULDOIROORZHGE\VXWXULQJRIWKHGHIHFWLYH LQQHU PHGXOOD SRUWLRQ ZLWK DEVRUEDEOH VXWXUH PDWHULDO7KHQERWKHQGVRIWKHUHVHFWLRQPDUJLQ
including the renal cortex and the outer zone of the
UHQDOPHGXOODZHUHDSSUR[LPDWHGZLWKSUHSDUHG
absorbable suture materials which were comprised of
cm in size) and a Hem-O-Lok® clipped outside. Knot
was made in advance at the distal one third of suture
PDWHULDOEHIRUHVXWXULQJWRSUHYHQWWKHSRO\WHWUDÀXR -roethylene and a Hem-O-Lok® clip from slipping off.
7KHSUHSDUHGVXWXUHPDWHULDOZDVSDVVHGWKURXJKWKH
renal parenchyma once on each side of the resection
PDUJLQDQGDQRWKHUVWULSRIH[SDQGHGSRO\WHWUDÀXRUR -ethylene and a Hem-O-Lok®ZDVDSSOLHG7KHQERWK
sides of the resection margin were cinched and the
VXWXUHPDWHULDOZDVWLHG2[LGL]HGFHOOXORVH6XUJL -cel®ZDVDSSOLHGLIQHHGHG7KHSURFHGXUHZDVWKHQ
WHUPLQDWHG)LJXUHVDQG
Figure 1 – Mono-material method (Gore-tex® only). A) The renal tumor was resected with a 1 cm margin. B) The exposed collecting system and vessels were repaired. C) Both ends of the resection margin were sutured with prepared 2-0 absorbable suture materials, ZKLFKZHUHFRPSULVHGRIDVWULSRIH[SDQGHGSRO\WHWUDÀXRURHWK\OHQHXVLQJWKHYHUWLFDOPDWWUHVVVXWXUHPHWKRG
Figure 2 – Combination-material method (Gore-tex® & Hem-O-Lok®). A) The renal tumor was resected with a 1 cm or adequate available margin. B) The exposed collecting system and vessels were repaired. C) Both ends of the resection margin were sutured with SUHSDUHGDEVRUEDEOHVXWXUHPDWHULDOVZKLFKZHUHFRPSULVHGRIDVWULSRIH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH'.QRWZDVPDGHLQ advance at distal one third of the suture material. Several Hem-O-Lok® clips were applied just proximally to knots and outside of the strips, preventing suture material from slipping and the renal parenchyma was cinched followed by tying of the suture materials.
A
B
C
A
B
RESULTS
7KHGHPRJUDSKLFDQGSHULRSHUDWLYHGDWDDUH SUHVHQWHGLQ7DEOH7XPRUORFDWLRQDWXSSHUPLG XSSHUPLGPLGORZHUDQGORZHUSROHZHUH DQGFDVHVUHVSHFWLYHO\0DVVHVZHUHSUHVHQWHGDV FDVHVRIH[RSK\WLFVKDSHFDVHVRILQWUDSDUHQ
-FK\PDOORFDWLRQDQGFDVHVRIPL[HGW\SH7KHUH
was one case of bilateral angiomyolipoma and none of solitary kidney. Several presenting locations and
VKDSHVRIWXPRURQ&7LPDJLQJWDNHQDWSUHDQGSRVW RSHUDWLYHSHULRGDUHSUHVHQWHGLQ)LJXUH3DWKRORJLF VWDJHRIUHQDOFHOOFDUFLQRPDFDVHVZHUHRIS7 S7RIS7(OHYHQFDVHVRI)XKUPDQ¶VQXFOHDU JUDGH,WKLUW\¿YHFDVHVRIJUDGH,,WKUHHFDVHVRI JUDGH,,,DQGRQHFDVHRIJUDGH,9ZHUHSUHVHQWHG ,QDOOFDVHVH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH DORQHRUWKHFRPELQDWLRQRIH[SDQGHGSRO\WHWUDÀXRUR -ethylene and Hem-O-Lok®ZHUHVXFFHVVIXOLQREWDLQ
-ing strict hemostasis of the surgical bed dur-ing surgery.
)XUWKHUPRUHQRSDWLHQWKDGDQ\HYLGHQFHRIDFXWHRU
delayed bleeding which required blood transfusion.
7KHUHZHUHQRSUREOHPVZLWKLPPHGLDWHRUGHOD\HG XULQHOHDNDJHLQDQ\RIWKHSDWLHQWVDWWKHPRQWK
follow-up evaluation. Our reconstruction technique did not require ureteral stent or catheter indwelling
LQDQ\FDVHV0RUHRYHUQRQHSKURQVZHUHLPSDLUHG DIWHUWKHQHSKUHFWRP\LQDQ\FDVH7KHSRVWRSHUDWLYH SDWKRORJLFGDWDDUHSUHVHQWHGLQ7DEOH7ZRUHQDO
cell carcinoma patients from group 2 had metastatic lesions at liver at postoperative follow-up period. One
FDVHZDVDFPVL]HGWXPRULQDSDWLHQWZLWKLQ
-Figure 3 – Firm renal parenchyma after the combination-mate-rial method.
Table 1 – Demographic and perioperative data.
Variables Group 1 Group 2
N patients 26
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1JHQGHU
Male
)HPDOH
7XPRUVKDSH
([RSK\WLF
Intraparenchymal 5
Mixed
Mean
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3UHRS&UOHYHOPJG/ +
3RVWRSPRQWKV&U/HYHOPJG/
&ROGLVFKHPLFWLPHPLQ
3UHRSKHPRJORELQ
Figure 4 – Preoperative (upper) and postoperative (lower) CT or MR images of various tumor locations and shapes. A) Left renal upper pole mass and intraparechymal type presentation. B) Right renal midportion mass. C) Left renal lower pole mass. D) Left renal hilar mass.
A
B
traparenchymal type at initial presentation who had a
PHWDVWDWLFOHVLRQDW\HDUVIROORZXS3DWKRORJ\ZDV DFRQYHQWLRQDOFOHDUFHOOW\SHZLWK)XKUPDQ¶VQXFOHDU
grade II. Another patient had a pulmonary metastatic renal cell carcinoma with 5 cm-sized primary tumor at initial presentation. Cytoreductive partial nephrec-tomy was performed and metastatic lesion at liver
GHYHORSHGDIWHURQH\HDUSRVWRSHUDWLYHO\3DWKRORJ\ ZDV D FRQYHQWLRQDO FOHDU FHOO W\SH ZLWK )XUPDQ¶V
nuclear grade III.
COMMENTS
3DUWLDOQHSKUHFWRP\LVEHFRPLQJWKHVWDQGDUG RIFDUHIRUVHOHFWHG7DUHQDOFHOOWXPRUV)RUUHQDO FHOOFDUFLQRPDV FP LQ GLDPHWHU WKH ORFDO UHFXU FP LQ GLDPHWHU WKH ORFDO UHFXUFPLQGLDPHWHUWKHORFDOUHFXU
-UHQFHUDWHDIWHUSDUWLDOQHSKUHFWRP\LVZLWK QRVLJQL¿FDQWGLIIHUHQFHVLQVXUYLYDOUDWHVEHWZHHQ
patients who have undergone radical nephrectomy
:LWKWKHLQFUHDVLQJIRFXVRQPLQLPDOO\LQYDVLYH VXUJHU\DGYDQFHGDEODWLYHDQGFRPSOH[UHFRQVWUXF -tive procedures are being performed laparoscopically.
7KHUHIRUH/31KDVHPHUJHGDVDQDWWUDFWLYHWUHDWPHQW
modality for select patients with small renal tumors.
%\GXSOLFDWLQJHVWDEOLVKHGVXUJLFDOSULQFLSOHVUHFHQW WHFKQLTXHVRI/31FRPELQHWKHDGYDQWDJHVRIPLQL -mally invasive surgery and the time-tested oncologic
DQGUHFRQVWUXFWLYHHI¿FDF\RI231+RZHYHU WKHWZRPRVWVLJQL¿FDQWFKDOOHQJHVIDFLQJWKHXURORJLF VXUJHRQGXULQJ/31LQFOXGHEOHHGLQJFRQWURODQGFRO -lecting system repair. When the indications for partial
QHSKUHFWRP\DUHH[SDQGHGHJLQSDWLHQWVZLWKPXO
-WLSOHWXPRUVPRUHFHQWUDOO\ORFDWHGWXPRUVRUWXPRUV!
FPLQVL]HWKHULVNRIWKHVSHFL¿FWHFKQLFDOO\UHODWHG FRPSOLFDWLRQVLQFUHDVH,QRSHQVXUJHU\YDULRXVWHFK -niques have been used to assist with hemostasis of the
WUDQVHFWHGUHQDOVXUIDFHLQFOXGLQJWHPSRUDU\YDVFXODU RFFOXVLRQYHVVHOVXWXUHOLJDWLRQUHQDOFRPSUHVVLRQ DQGVSHFLDOVXUJLFDOHTXLSPHQW+RZHYHULWLVWKHVH
challenges of hemostasis and collecting system closure that have limited the application of nephron-sparing
VXUJHU\LQODSDURVFRS\DVHYLGHQFHGE\WKHLQLWLDOH[
-SHULHQFHZLWKODSDURVFRSLFSDUWLDOQHSKUHFWRP\ZKLFK FDUULHVDKLJKULVNRIFRPSOLFDWLRQV,QIDFW
most cases of laparoscopic partial nephrectomy have shown successful results only in small tumor sizes.
'HVDLHWDOUHSRUWHGVXFFHVVIXOUHVXOWVLQVXWXUH
repair of the pelvicaliceal system with laparoscopy;
KRZHYHUWKHLUGDWDZDVREWDLQHGZLWKWXPRUVZLWK DPHDQVL]HRIFPDQGFPPD[LPXPVL]H,Q RXUVHULHVWKHPHDQWXPRUVL]HZDV!FPZKHQNQRW
tying was performed with the help of expanded
polytet-UDÀXRURHWK\OHQHDQG+HP2/RN®)XUWKHUPRUHWKH
ODUJHWXPRUFPLQGLDPHWHULQRXUVHULHVZKLFK RFFXSLHGQHDUO\RQHWKLUGRIWKHNLGQH\GLGQRWUHVXOW
in any acute or delayed complications following suc-cessful renal parenchymal repair with the combined
PHWKRG)LJXUH
5HFHQWO\FRPPHUFLDOO\DYDLODEOH¿EULQWLVVXH
sealants and gelatin matrix-thrombin tissue sealants have been used to assist in hemostasis and collect-ing system closure durcollect-ing open and laparoscopic partial nephrectomy with apparent clinical success
'HVSLWH WKH JURZLQJ FOLQLFDO DSSOLFDWLRQ RIWKRVHPHWKRGVGXULQJSDUWLDOQHSKUHFWRP\WKHUH
exists little information with regard to the in vivo properties for preventing the major complications of
SDUWLDOQHSKUHFWRP\,QRXUVHULHVRWKHUDGGLWLRQDO
intracorporeal hemostatic agents were not necessary
EHFDXVHWKHWHQVLOHVWUHQJWKZDVVXI¿FLHQWWRNHHS WKHUHSDLUHGSDUHQFK\PD¿UPZLWKRXWDQ\DFXWHRU GHOD\HGFRPSOLFDWLRQVVXFKDVXULQHOHDNDJHRUKH
-PDWRPDIRUPDWLRQ([SDQGHGSRO\WHWUDÀXRURHWK\OHQH
and Hem-O-Lok®SURYLGHGVXI¿FLHQWWHQVLOHVWUHQJWK
H[WUDFRUSRUHDOO\WKHUHIRUHQRDGYHUVHUHDFWLRQVGXH WRIRUHLJQPDWHULDOVZDVH[SHFWHG7KXVRXUVXUJL -cal technique could prevent completely two major
FRPSOLFDWLRQVWKRVHDUHSRVWRSHUDWLYHKHPRUUKDJH
and urine leakage. It should be validated from large
VHULHV$FFRUGLQJWRUHFHQWODUJHVHULHVRQWKHRWKHU
Table 2 – Postoperative pathologic data.
Histological Features Group 1
1 Group 2 1
Renal cell carcinoma
Clear cell 26
Chromophobe 2
3DSLOODU\ 2
Angiomyolipoma 2
KDQGSRVWRSHUDWLYHKHPRUUKDJHDIWHU/31DQG231 ZHUHUHSRUWHGDWDQGRIFDVHVUHVSHFWLYHO\ 8ULQHOHDNDJHDIWHU/31DQG231ZHUHUHSRUWHGDW DQGRIFDVHVUHVSHFWLYHO\
7KHXVHRIH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH
preserved the remaining renal parenchyma without
LQMXU\VXFKDVWKH³FKHHVHVOLFLQJ´HIIHFWRINQRWW\
-LQJ+RZHYHUWKHH[SDQGHGSRO\WHWUDÀXRURHWK\OHQH VRPHWLPHVVKRZHGLQVXI¿FLHQWWHQVLOHVWUHQJWKIRU
keeping the “fragile” renal parenchyma safe from
in-MXU\7KHUHIRUHNQRWW\LQJGXULQJ231ZLWKH[SDQGHG SRO\WHWUDÀXRURHWK\OHQHRQO\WRRNH[FHVVLYHWLPHIRU FRUUHFWLQJWKHNQRWV,QRXUUHVXOWVWKHPHDQFROG LVFKHPLFWLPH&,7RIWKHFRPELQHGJURXSZDVORQJHU WKDQWKHPRQRPDWHULDOJURXSEXWZLWKRXWDVLJQL¿FDQW GLIIHUHQFHLQWLPH%DVHGRQWKHPHDQWXPRUVL]HWKH DFFHSWDEOHPHDQ&,7RIWKHFRPELQHGJURXSFRPSDUHG
with mono-material group could be explained in two
ZD\V)LUVWWKHFRPELQHGPHWKRGQHHGHGIHZHUDW -tempts for needle passing because cinching was
ob-WDLQHGZLWKWKHLQWHUUXSWHGVXWXUHPHWKRGZKLOHWKH
mono-material method required at least 2-fold more attempts due to the vertical mattress suture method.
6HFRQGWKHWHQVLOHVWUHQJWKZDVHDVLO\REWDLQHGZLWK
the combined method because Hem-O-Lok® offers
SDUDOOHOWHQVLRQWRWKHFDSVXODUVXUIDFHZKLOHWKHPRQR
material method delivers upward or downward forces perpendicular to the capsular surface.
,QUHVSHFWRIFDQFHUFRQWUROSDUWLDOQHSKUHF -tomy is comparable to radical nephrec-tomy. Since
\HDURXWFRPHGDWDDIWHUQHSKURQVSDULQJ VXUJHU\LQSDWLHQWVKDYHEHHQUHSRUWHG6SH
-FL¿FVXUYLYDOUDWHVRIFDQFHUZHUHDQGDW DQG\HDUVUHVSHFWLYHO\$QRWKHUUHSRUWDOVRVKRZHG
no difference between survival rates in patients who underwent radical nephrectomy and nephron sparing
VXUJHU\7XPRUVL]HDQGVWDJHZHUHWKHPDLQIDFWRUV RIRXWFRPHLQERWKJURXSV
Similar long-term outcome would be
ex-SHFWHGLQRXUVHULHVZKHUHDVWKHWXPRUVL]HFRXOGQRW
the primary determinant of outcome.
CONCLUSION
Nephron-sparing surgery using expanded
SRO\WHWUDIOXRURHWK\OHQH *RUH7H[®) alone or a
*RUH7H[® and Hem-O-Lok®:HFN® Clip)
combi-nation was relatively safe without other additional
KHPRVWDWLFDJHQWVLUUHVSHFWLYHRIWKHWXPRUVL]HDQG ORFDWLRQEHFDXVHWKHWHQVLOHVWUHQJWKZDVVXI¿FLHQWWR NHHSWKHUHSDLUHGSDUHQFK\PD¿UP)XUWKHUPRUHWKH
combined method afforded easier handling and less operation time than the mono-material method. No
PDMRUFRPSOLFDWLRQVUHFXUUHQFHDQGLPSDLUHGUHQDO
function occurred with either of the procedures.
CONFLICT OF INTEREST
None declared.
REFERENCES
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=LQFNH+5XFNOH+&8VHRIH[RJHQRXVPDWHULDOWR
bolster closure of the parenchymal defect following
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0+6KDOKDY$/(OLPLQDWLQJNQRWW\LQJGXULQJZDUP
ischemia time for laparoscopic partial nephrectomy. J
8URO
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world robotic urologic symposium. J Robotic Surg.
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/HUQHU 6( +DZNLQV &$ %OXWH 0/ *UDEQHU$ :ROODQ3&(LFNKROW-7HWDO'LVHDVHRXWFRPHLQ
patients with low stage renal cell carcinoma treated
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EDITORIAL COMMENT
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considered the best alternative in treatment of renal
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the comparable oncological outcomes to the
stan-GDUGUDGLFDOWUHDWPHQWDQGWKHUHPDUNDEOHEHQH¿WRI SUHVHUYLQJUHQDOIXQFWLRQ7KLVKDVJDLQHGPRUHUHO -evance after several studies that demonstrate higher risk of develop chronic renal failure after radical
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of nephron sparing surgery for localized renal cell
car-FLQRPD\HDUIROORZXS-8URO 0F'RXJDOO(0(OEDKQDV\$0&OD\PDQ59/DSD -roscopic wedge resection and partial nephrectomy--the Washington University experience and review of the
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Laparoscopic partial nephrectomy with suture repair of
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tissue sealant during laparoscopic partial nephrectomy.
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laparoscopically performed partial nephrectomy
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Accepted after revision: February 27, 2009
Correspondence address:
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advances in NSS have been reported with the aim of
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be useful in the management of larger and complex located tumors.
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described laparoscopic renorrhaphy techniques based
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providing a reliable and reproducible reconstruction.
7KHXVHRI:HFN+HP2ORFN® clips on the sutures
allows a more even distribution of the tension ap-plied on the renal surface with a consequent better coaptation. Studies developed in our laboratory have shown that the tension that can be applied on the
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times higher than the achieved with traditional knot tying. Maintaining the placed stitches perpendicular to the capsule when tightening aid-avoiding tears.
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if needed to achieve an optimal hemostasis.
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to the vertical mattress suture line to prevent paren-chymal tears is an interesting addition to the open
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even distribution of tension. Its use could gain
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renal capsule has been damaged or when clips are not
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of these advances could be the explanation for the
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represented in the almost non-existent complications reported in the paper.
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and single-surgeon experience are present in this and many other studies. A randomized prospective study comparing this new approach to the traditional partial nephrectomy technique using a knot-tying reconstruc-tion could be a valuable addireconstruc-tion to establish differ-ences.
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despite of living in a minimally invasive surgery
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of excellence in the armamentarium of urologists
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to this classical technique will always be welcome.
REFERENCES
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*R$6&KHUWRZ*0)DQ'0F&XOORFK&(+VX &<&KURQLFNLGQH\GLVHDVHDQGWKHULVNVRIGHDWK FDUGLRYDVFXODUHYHQWVDQGKRVSLWDOL]DWLRQ1(QJO -0HG(UUDWXPLQ1(QJO-0HG
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ischemia time for laparoscopic partial nephrectomy.
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renal parenchymal suture repair during laparoscopic
SDUWLDOQHSKUHFWRP\8URORJ\ %KD\DQL6)LJHQVKDX57KH:DVKLQJWRQXQLYHUVLW\
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EDITORIAL COMMENT
In patients with a normal contralateral kidney
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imperative indication for nephron sparing surgery.
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6HYHUDO WHFKQLTXHV H[LVW IRU 31( ZLWK YDULRXVPRGL¿FDWLRQV,WVWDUWVZLWKWKHRSHUDWLYH DFFHVVZKLFKGHSHQGVVWURQJO\RQWKHWXPRUSRVL -tion. Ischemia time is a crucial issue. In anticipated
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consensus to use hypothermia via arterial perfusion
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is done in warm ischemia with occlusion of only the
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cold perfusion is foreseen in order to avoid intimal
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easily applicable without additional measurements.
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is feasible with good differentiation between normal and tumor tissue minimizing the risk of unrecognized positive surgical margins.
We achieve laparoscopy hemostasis by two layers of running sutures and knot tying supported by
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edges of the parenchyma are then adapted by a second
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avoid the suture cutting through parenchymal tissue
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procedure in respect to intra-/postoperative
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reduction of functional parenchyma loss by the use of
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is obvious that glue cannot deal with large tumors and
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safety is limited in the individual case.
A very comprehensive study in a hypertensive
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to deal with reliable closure of large parenchymal
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is the time for suture placement and tying which can-not be neglected in a procedure in which time really
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procedures in which suturing generates a by far higher delay than in open surgery.
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an objective rationale for the decision. All surger-ies showed no side effects perioperatively as well as in long term follow up which was extended to
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side effects and long term renal function. Based on this rich experience a switch to laparoscopy should be considered in order to provide optimal up to date patient care.
REFERENCES
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versus open partial nephrectomy for renal tumors in
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of techniques used for the production of temporary
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