SIU 2017: Optimizing Renal Function Following Surgery for Localized Kidney Cancer - Optimizing Excision and Reconstruction

Lisbon, Portugal (UroToday.com) Dr. Kondo focused on surgical techniques (excision and reconstruction) to preserve renal function. Dr. Kondo’s made some excellent points to consider from a technical standpoint.

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

3. Renorrhaphy
  • 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
            - He still does a capcular repair for MIS NSS
            - 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
5. Hemostatic agents
  • 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.