AUA 2018: Tips and Tricks – Open Partial Nephrectomy

San Francisco, CA ( Van Poppel, MD, from Belgium presented the European Urological Association (EAU) lecture, discussing his personal experience with open partial nephrectomy. Van Poppel started by highlighting that the EAU guidelines state that (i) patients with T1 renal masses should undergo nephron-sparing surgery rather than radical nephrectomy whenever possible, and (ii) for solitary renal tumors up to a diameter of 7cm, nephron-sparing surgery is the standard procedure, whenever technically feasible. Generally, these statements are echoed by the AUA guidelines. Additionally, Van Poppel highlights that nephron-sparing surgery confers a cardiac-specific survival advantage compared to those undergoing radical nephrectomy.

Van Poppel prefers to make a flank incision for his open partial nephrectomies, highlighting that either following the 11th or 12th rib (preferably without rib resection) is adequate. He notes that one should be cognizant to spare the intercostal nerve, as well as avoid pneumothorax when entering the retroperitoneum. To assist with pain post-operatively, he recommends a high-stay epidural. Particularly for flank incisions, he makes sure to take time with his incision close to avoid downstream postoperative pain, neuralgia, muscle paresis, bulging, and hernias. 

Once in the retroperitoneum, he completely mobilizes the kidney, taking care to remove what he calls the “toxic” fat around the kidney, which is certainly easier in females than males. To assist with tumor resection, he completely exteriorizes the kidney. For small RCC tumors, particularly clear cell histology which typically has a pseudocapsule, he prefers enucleation to spare additional nephrons, but also notes that he is not afraid to do a wedge resection if necessary. To do a pure enucleation, he highlights that it is key to get into the appropriate plane of the pseudocapsule in order to avoid a positive margin, as well as refrain from taking healthy kidney tissue. For a straightforward partial nephrectomy, he will clamp both the artery and vein to allow the operation to take place in an essentially bloodless field. For larger tumors, the same principles remain, however, Van Poppel also notes that one should refrain from early unclamping before the renorrhaphy is complete. Certainly, with larger tumors, surgery is more complex/challenging requiring greater reconstruction, which can lead to a longer ischemia time. For these cases, Van Poppel feels intra-operative ultrasound is critical for pre-excision planning of lateral margins and depth of resection. For these cT1b tumors, Van Poppel states at a warm ischemia time of 25-30 minutes is acceptable. 

Van Poppel concluded with several important take-home messages:

  • Remove as few nephrons as possible
  • Keep warm ischemia time within 20-25 minutes, when possible
  • Do easy cases with laparoscopic or robotic assistance
  • Risky tumors and solitary kidneys are safest with an open approach
Presented by: Hein Van Poppel, MD, University Hospitals, KU Leuven, Leuven, Belgium

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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