Improved Closure Techniques for Laparoscopic Partial Nephrectomy in Moderately Complex Renal Cell Carcinoma
Laparoscopic partial nephrectomy (LPN) has emerged as a minimally invasive nephron-sparing surgery, increasingly favored for the treatment of T1a renal carcinoma. This preference stems from its ability to facilitate faster post-operative recovery while delivering oncological outcomes equivalent to those of radical nephrectomy. However, the complexity of renal tumors presents significant challenges in performing LPN, often resulting in prolonged warm ischemic time (WIT), which adversely affects post-operative renal function recovery. To address this issue, this study introduces improved closure techniques for LPN, specifically focusing on early unclamping (EUC) in patients with moderately complex renal cell carcinoma (RCC). The effectiveness of these techniques is evaluated through a retrospective analysis of clinical data from 130 patients.
The study was conducted between February 2012 and June 2016 at The Third Affiliated Hospital of the Naval Military Medical University and Changzheng Hospital. Patients included in the study were diagnosed with moderately complex RCC, as indicated by a R.E.N.A.L. score of 7–9. The R.E.N.A.L. nephrometry score is a standardized system used to assess the complexity of renal tumors based on factors such as tumor size, location, and proximity to critical structures. Exclusion criteria encompassed the absence of informed consent and a follow-up period of less than one year. Pre-operative, intra-operative, post-operative, and follow-up data were meticulously collected and analyzed.
The improved-EUC (I-EUC) technique was developed to address the limitations of the standard unclamping (SUC) method. In the I-EUC group, the renal artery was clamped using an artery clip after the exposure of the renal cancer and peripheral renal parenchyma. Tumor resection was performed using cold scissors, ensuring the excision of adjacent normal tissues 0.5 cm away from the tumor edge. A 3-0 absorbable barbed suture was employed to continuously suture the deep wound of the renal parenchyma and collective system. The tail of the 2-0 absorbable barbed suture was clamped using Hem-o-lock clips, facilitating rapid continuous sutures with large intervals along the outer layer of the wound. This approach ensured the apposition of the wound margin and significantly shortened the WIT. The artery clip was unclamped after suturing the second layer, restoring renal blood flow. The final layer was sutured in an “8”-shaped direction, consolidating the wound edges and ensuring hemostasis. Careful observation of the wound bed confirmed firm sutures and the absence of significant hemorrhage.
In contrast, the SUC group adhered to traditional procedures, where the artery clip was unclamped only after completing all three suture layers. Statistical analysis was performed using SPSS 19.0 software, with categorical variables evaluated using the Chi-square test and continuous variables assessed via Student’s t test or the Wilcoxon rank-sum test. A P value of less than 0.05 was considered statistically significant.
The study included 130 patients, with 72 in the SUC group and 58 in the I-EUC group. Baseline demographics and tumor characteristics were comparable between the two groups, with no significant differences in sex allocation, age, body mass index, Eastern Cooperative Oncology Group performance status, smoking history, hypertension, diabetes, serum creatinine, blood urea nitrogen, American Society of Anesthesiologists (ASA) score, or R.E.N.A.L. score. Operative outcomes revealed a significantly shorter mean WIT in the I-EUC group compared to the SUC group (P < 0.001). No patients required intra-operative or delayed post-operative blood transfusions, and there were no significant differences in mean estimated blood loss (EBL), mean operative duration, post-operative complications, positive margin rates, or mean length of post-operative hospital stay between the two groups.
Follow-up data indicated no significant differences in pre-operative estimated glomerular filtration rate (eGFR) or eGFR reduction at 3 and 6 months post-LPN between the two groups. However, 12 months after LPN, the SUC group exhibited significantly slower serum eGFR recovery compared to the I-EUC group (P = 0.013). The final analysis revealed a significantly greater eGFR decline in the SUC group 12 months post-LPN (P = 0.004). No instances of local recurrence or distant metastasis were observed during the follow-up period.
The development of laparoscopic techniques has underscored the importance of minimizing ischemic time to preserve renal function. Various strategies, including earlier arterial unclamping, selective arterial clamping, “zero ischemia,” selective segmental arterial clamping, and off-clamp techniques, have been proposed to reduce WIT. However, these methods are primarily applicable to uncomplicated small RCCs and require significant surgical expertise. In complex RCCs, the repeatability of these techniques is limited. The I-EUC method addresses these challenges by unclamping the artery clips after rapid and continuous suturing of the renal parenchyma, ensuring less errhysis and better wound apposition. The “1” method further enhances hemostasis by continuously suturing points of errhysis after unclamping the artery clips.
The I-EUC technique provides sufficient time for tumor excision and wound bed suturing, making it accessible to experienced surgeons and improving its repeatability among LPN learners. Compared to the SUC method, the I-EUC suturing technique significantly reduces WIT and minimizes eGFR decline 12 months post-operatively. The “2 + 1” suturing method offers more accurate and firm suture effects, clearer vision, adequate hemostasis, and a shorter learning curve.
In conclusion, the I-EUC technique effectively reduces WIT and minimizes eGFR decline by improving suturing methods and employing EUC in the laparoscopic treatment of moderately complex RCCs. This approach enhances patients’ quality of life, expands the applicability of LPN, and improves its safety, warranting clinical promotion.
doi.org/10.1097/CM9.0000000000001052
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