1. Enucleation vs. standard PN
- In terms of oncologic outcomes, most recent studies have suggested similar outcomes
- However, in terms of renal function, enucleation seems be associated with more renal parenchymal preservation
- As such, we should consider enucleation more often for CKD patients – if negative SM are thought to be feasible. Ultimately cancer outcomes are most important – re-operations for recurrent disease do not benefit the patient.
2. Renal bed repair in NSS
- Dr. Konto made a very good point regarding the inner suture of the renal bed during NSS
- It is very important to NOT take big bites when doing this repair – more likely to tie of deep segmental arteries (arterial blood supply to the very parenchyma you are trying to preserve)!
- He uses a smaller needle and takes shallow bites for the renal bed hemostatic repair
- He also addressed renorrhaphy capsular repair technique
- It has yet to be proven the operative benefit of capcular repair – however, the hemostatic benefit appears to be clear
- However, for open repairs, he has started to shift away from it
- Deep bites can devascularize the parenchyma you are trying to preserve
4. Early unclamping
- Originally initiated to reduce warm ischemia time and reduce ischemic damage
- However, while it has been shown to potentially reduce short term renal function, it does not appear to be associated with long-term GFR recovery
- It has been shown in some series to be associated with less incidence of pseudoaneurysm development
- Blood loss must be weighed against ischemia injury in any NSS
- Postoperative bleeding continues to occur in 5.6% after robotic partial nephrectomy
- While most studies have not shown any significant benefit, it is still widely utilized in the real world – likely habitual
- Unclear that it would have any effect on renal function recovery
These are all excellent points from Dr. Kondo.
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal