NARUS 2018: Different Techniques of RPN: Hilar Control, Excision, Renorrhaphy

Las Vegas, NV ( At the Renal session at NARUS 2018, presentations included three different robotic experts regarding their approach to robotic partial nephrectomy renorrhaphy.

As moderator, Dr. Sam Bhayani started by discussing the primary concerns during robotic partial nephrectomy, which include (i) cancer control, (ii) avoiding major complications, (iii) saving the kidney, and (iv) demonstrating a reproducible technique. Secondary concerns include (i) ischemic time, (ii) saving parenchyma, and (iii) incremental outcomes compared to partial vs radical nephrectomy. 

Dr. Craig Rogers presented his technique first, noting that his basic concepts are to “keep it old school”. By this he (i) completely clamps the renal artery using robotic bulldog clamps (warm ischemia time <25 min), (ii) excises the tumor with a margin confirmed on ultrasound, and (iii) performs a two-layer renorrhaphy. This two-layer closure includes a deep inner running layer with a 3-O monocryl suture on an SH needle, and an outer capsular layer using an interrupted 2-O vicryl suture on a CT-1 needle. Dr. Rogers concludes that there are many techniques out there, but by keeping it old school he keeps it simple and reproducible. 

Dr. Chandru Sundaram subsequently presented his technique of non-cortical renorrhaphy noting that at his institution they did a matched analysis of robotic partial nephrectomy procedures omitting cortical renorrhaphy to those undergoing traditional renorrhaphy, noting no difference in complications between these cohorts. Margins were similar between the group, however, importantly there was a statistically significant less kidney volume loss for patients undergoing non-cortical renorrhaphy (p=0.003).

Finally, Dr. Ronney Abaza presented his technique, noting that in his first 400 robotic partial nephrectomies he has had no AV fistulas/pseudoaneurysms/IR embolizations and only three perioperative transfusions, which he attributes to his technique. Dr. Abaza’s preference is a deep layer with two overlapping running sutures, followed by a capsular layer that goes through the entire defect instead of across the defect:

 In Dr. Abaza’s opinion, this truly suture ligates any potential vessels in the defect bed and prevents creation of “dead-space” between the cortical edges that otherwise may lead to AV fistulas and pseudoaneurysms. In order to perform this stitch, he has on hand a box of large sutures, which he calls the “Giant Needle Club”. These include large CTX vicryl sutures (amongst others). In his opinion, with proper needle size selection any repair can be successfully traversed, even for cases involving a hemi-nephrectomy.

Speakers: Sam Bhayani, Washington University School of Medicine, St. Louis, MO; Craig Rogers, Henry Ford Hospital, Detroit, MI; Chandru Sundaram, Indian University School of Medicine, Indianapolis, IN; Ronney Abaza, OhioHealth Dublin Methodist Hospital, Dublin, OH

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV