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NEPHRON SPARING SURGERY FOR RENAL CELL CARCINOMA USING SELECTIVE RENAL PARENCHYMAL CLAMPING
0022-5347/02/1671-0234/0 THE JOURNAL OF UROLOGY® Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 167, 234 –235, January 2002 Printed in U.S.A.
NEPHRON SPARING SURGERY FOR RENAL CELL CARCINOMA USING SELECTIVE RENAL PARENCHYMAL CLAMPING ARNAUD MEJEAN, BENOIT VOGT, SEBASTIEN CAZIN, CHANT BALIAN, JEAN FRANC ¸ OIS POISSON AND BERTRAND DUFOUR From the Department of Urology, Hoˆpital Necker, Paris, France
ABSTRACT
Purpose: We describe a technical artifice facilitating nephron sparing surgery for renal cell carcinoma without clamping the renal pedicle. Materials and Methods: Selective renal parenchymal clamping was performed using a large curved DeBakey aortic clamp placed around and sufficiently far from the tumor. The lesion was resected with a surrounding margin of normal renal parenchyma. The intrarenal vessels were suture ligated and the collecting system was closed as necessary. Time was not limited since the artery was not clamped. Results: Ten patients with renal cell carcinoma in whom nephron sparing surgery was indicated underwent selective renal parenchymal clamping. The indication was elective in 8 patients and urgent in 2. The tumor was at the renal pole in 3 cases and peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Blood loss was insignificant. Operative time was 81 minutes (range 61 to 125) and there were no perioperative or postoperative complications. Conclusions: Selective renal parenchymal clamping is a simple and efficient technical maneuver for facilitating nephron sparing surgery without pedicle dissection and clamping for renal peripheral or pole tumors. Neoplasm location and size are the limiting factors of this technique. KEY WORDS: kidney; carcinoma, renal cell; surgical instruments; nephrectomy
Nephron sparing surgery for renal cell carcinoma is usually performed in patients with bilateral disease, renal cell carcinoma involving a solitary functioning kidney or when the opposite kidney is affected by a condition that may threaten future function. The incidental discovery of a tumor of 40 mm. or less in patients with a normal contralateral kidney tends to be an indication for nephron sparing surgery.1 It is widely recommended to remove up to 10 mm. of normal tissue around the pseudocapsule of the tumor. Bleeding can be controlled by artery or pedicle vascular occlusion and renal cooling is achieved by ice placed on the kidney surface.2– 4 Therefore, it is necessary to dissect and divide the pedicle with the associated risk of vascular injury. Clamping the vessels can cause an injurious period of ischemia. We describe a technical maneuver to facilitate nephron sparing surgery without clamping the renal pedicle. MATERIALS AND METHODS
The incision involved a flank approach on the 11th rib. The kidney was freed from the fatty tissue except around the tumor. Selective renal parenchymal clamping circumscribing the tumor was performed using a large curved DeBakey aortic clamp (fig. 1). Clamping pressure was controlled by a surgical loop tied by Kocher forceps to avoid crushing the kidney (fig. 1). Wedge resection was performed (fig. 2). Frozen section analysis was done to determine surgical margin status. The prominent intrarenal vessels within the transected parenchyma were suture ligated. When it was entered, the collecting system was closed with continuous 5-zero absorbable sutures. The renal defect was closed on itself using separated absorbable 2-zero U sutures gently tied over small pieces of absorbable knitted oxidized cellulose fabric. The clamp was removed. A Penrose drain remained in place. Accepted for publication August 10, 2001.
FIG. 1. Large curved DeBakey aortic clamp circumscribing tumor. Inset shows clamping pressure is controlled by surgical loop tied with Kocher forceps.
RESULTS
During the last 3 months we performed nephron sparing surgery with selective renal parenchymal clamping in 10 patients 45 to 78 years old (mean age 58) with renal cell carcinoma. The indication was elective in 8 cases and imperative in 2. The tumor was at the renal pole in 3 patients and
234
NEPHRON SPARING SURGERY USING SELECTIVE RENAL PARENCHYMAL CLAMPING
FIG. 2. Peripheral 28 mm. right kidney tumor. A, CT. B, after removal of fatty tissue. Pedicle was not dissected. C, after selective renal parenchymal clamping. D, wedge resection with margin of normal kidney and intrarenal vessels ligated (arrows).
peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Frozen section analysis confirmed normal surgical margin status. The collecting system and vessels were closed or sutured. Mean operative time was 81 minutes (range 68 to 125). Intraoperative blood loss was insignificant. No complications were observed, including urinary flank drainage or renal dysfunction. Mean hospital stay was 7.8 days (range 5 to 11). DISCUSSION
Nephron sparing surgery is usually performed with renal artery occlusion. Access to the renal artery is timeconsuming and potentially dangerous. The advantage is the control of bleeding but the risk involves renal ischemia. Operative time is supposed to be limited to 30 to 60 minutes for closing the collecting system and suturing the prominent vessels. Nevertheless, the most common complications after nephron sparing surgery are urinary fistula in 17% of cases and acute failure of a solitary kidney in 26%.5 Other surgeons use fingers to circumscribe the tumor but to us it seems inaccurate. We propose a simple technical maneuver using a large curved vascular clamp for circumscribing the tumor according to appropriate lesion size and location. Selective renal parenchymal clamping is useful for controlling bleeding, making pedicle dissection unnecessary.
235
Operative time is decreased, renal cooling is unnecessary and the incision may be smaller. Nephron ischemia does not affect the remainder of the renal parenchyma, and so the surgeon has time to perform nephron sparing surgery, suture the vessels and close the collecting system and renal defect. Margin sectioning and hemostasis are perfectly controlled. Clamping pressure can be progressively released to improve hemostasis before closing the renal defect. Frozen section analysis of surgical margin status can be done carefully. When using this maneuver in the initial 10 patients, we did not observe blood loss or surgical complications. A similar technique was described by Gill et al using a tourniquet,6 and by Cariou and Cussenot7 using 2 clamps. However, these techniques were essentially useful for renal pole lesions. Most small tumors for which nephron sparing surgery is indicated are peripheral on the convex line, often with extrarenal development. Selective renal parenchymal clamping is feasible using this clamp for renal tumors, provided that it widely circumscribes the tumor. The point is the size and location of the intraparenchymal portion of the neoplasm. In cases of a large central or hilar tumor, or tumor close to the pedicle it is more difficult to circumscribe the mass and the classic technique with renal artery occlusion and renal surface cooling is required. Clamping pressure must be controlled by a loop to avoid crushing the kidney. Because the rack is too short, a new clamp with a large rack is currently being manufactured to facilitate the procedure. In conclusion, selective renal parenchymal clamping is a simple and efficient technical maneuver for nephron sparing surgery in a large number of renal tumor cases that does not necessitate any specific investment. REFERENCES
1. Uzzo, R. G. and Novick, A. C.: Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol, 166: 6, 2001 2. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol Clin North Am, 14: 419, 1987 3. Bazeed, M. A., Scharfe, T., Becht, E. et al: Conservative surgery of renal cell carcinoma. Eur Urol, 12: 238, 1986 4. Chretien, Y., Mejean, A., Cazalaa, J. B. et al: Conservative surgical techniques in the treatment of kidney tumors. Progr Urol, 10: 134, 2000 5. Campbell, S. C., Novick, A. C., Streem, S. B. et al: Complications of nephron sparing surgery for renal tumors. J Urol, 151: 1177, 1994 6. Gill, I. S., Munch, L. C., Clayman, R. V. et al: New renal tourniquet for partial nephrectomy. J Urol, 154: 1113, 1995 7. Cariou, G. and Cussenot, O.: Haemostasis technique in partial nephrectomy. Progr Urol, 6: 605, 1996
Vol. 167, 234 –235, January 2002 Printed in U.S.A.
NEPHRON SPARING SURGERY FOR RENAL CELL CARCINOMA USING SELECTIVE RENAL PARENCHYMAL CLAMPING ARNAUD MEJEAN, BENOIT VOGT, SEBASTIEN CAZIN, CHANT BALIAN, JEAN FRANC ¸ OIS POISSON AND BERTRAND DUFOUR From the Department of Urology, Hoˆpital Necker, Paris, France
ABSTRACT
Purpose: We describe a technical artifice facilitating nephron sparing surgery for renal cell carcinoma without clamping the renal pedicle. Materials and Methods: Selective renal parenchymal clamping was performed using a large curved DeBakey aortic clamp placed around and sufficiently far from the tumor. The lesion was resected with a surrounding margin of normal renal parenchyma. The intrarenal vessels were suture ligated and the collecting system was closed as necessary. Time was not limited since the artery was not clamped. Results: Ten patients with renal cell carcinoma in whom nephron sparing surgery was indicated underwent selective renal parenchymal clamping. The indication was elective in 8 patients and urgent in 2. The tumor was at the renal pole in 3 cases and peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Blood loss was insignificant. Operative time was 81 minutes (range 61 to 125) and there were no perioperative or postoperative complications. Conclusions: Selective renal parenchymal clamping is a simple and efficient technical maneuver for facilitating nephron sparing surgery without pedicle dissection and clamping for renal peripheral or pole tumors. Neoplasm location and size are the limiting factors of this technique. KEY WORDS: kidney; carcinoma, renal cell; surgical instruments; nephrectomy
Nephron sparing surgery for renal cell carcinoma is usually performed in patients with bilateral disease, renal cell carcinoma involving a solitary functioning kidney or when the opposite kidney is affected by a condition that may threaten future function. The incidental discovery of a tumor of 40 mm. or less in patients with a normal contralateral kidney tends to be an indication for nephron sparing surgery.1 It is widely recommended to remove up to 10 mm. of normal tissue around the pseudocapsule of the tumor. Bleeding can be controlled by artery or pedicle vascular occlusion and renal cooling is achieved by ice placed on the kidney surface.2– 4 Therefore, it is necessary to dissect and divide the pedicle with the associated risk of vascular injury. Clamping the vessels can cause an injurious period of ischemia. We describe a technical maneuver to facilitate nephron sparing surgery without clamping the renal pedicle. MATERIALS AND METHODS
The incision involved a flank approach on the 11th rib. The kidney was freed from the fatty tissue except around the tumor. Selective renal parenchymal clamping circumscribing the tumor was performed using a large curved DeBakey aortic clamp (fig. 1). Clamping pressure was controlled by a surgical loop tied by Kocher forceps to avoid crushing the kidney (fig. 1). Wedge resection was performed (fig. 2). Frozen section analysis was done to determine surgical margin status. The prominent intrarenal vessels within the transected parenchyma were suture ligated. When it was entered, the collecting system was closed with continuous 5-zero absorbable sutures. The renal defect was closed on itself using separated absorbable 2-zero U sutures gently tied over small pieces of absorbable knitted oxidized cellulose fabric. The clamp was removed. A Penrose drain remained in place. Accepted for publication August 10, 2001.
FIG. 1. Large curved DeBakey aortic clamp circumscribing tumor. Inset shows clamping pressure is controlled by surgical loop tied with Kocher forceps.
RESULTS
During the last 3 months we performed nephron sparing surgery with selective renal parenchymal clamping in 10 patients 45 to 78 years old (mean age 58) with renal cell carcinoma. The indication was elective in 8 cases and imperative in 2. The tumor was at the renal pole in 3 patients and
234
NEPHRON SPARING SURGERY USING SELECTIVE RENAL PARENCHYMAL CLAMPING
FIG. 2. Peripheral 28 mm. right kidney tumor. A, CT. B, after removal of fatty tissue. Pedicle was not dissected. C, after selective renal parenchymal clamping. D, wedge resection with margin of normal kidney and intrarenal vessels ligated (arrows).
peripheral in 7. Mean tumor size was 32 mm. (range 19 to 52). Frozen section analysis confirmed normal surgical margin status. The collecting system and vessels were closed or sutured. Mean operative time was 81 minutes (range 68 to 125). Intraoperative blood loss was insignificant. No complications were observed, including urinary flank drainage or renal dysfunction. Mean hospital stay was 7.8 days (range 5 to 11). DISCUSSION
Nephron sparing surgery is usually performed with renal artery occlusion. Access to the renal artery is timeconsuming and potentially dangerous. The advantage is the control of bleeding but the risk involves renal ischemia. Operative time is supposed to be limited to 30 to 60 minutes for closing the collecting system and suturing the prominent vessels. Nevertheless, the most common complications after nephron sparing surgery are urinary fistula in 17% of cases and acute failure of a solitary kidney in 26%.5 Other surgeons use fingers to circumscribe the tumor but to us it seems inaccurate. We propose a simple technical maneuver using a large curved vascular clamp for circumscribing the tumor according to appropriate lesion size and location. Selective renal parenchymal clamping is useful for controlling bleeding, making pedicle dissection unnecessary.
235
Operative time is decreased, renal cooling is unnecessary and the incision may be smaller. Nephron ischemia does not affect the remainder of the renal parenchyma, and so the surgeon has time to perform nephron sparing surgery, suture the vessels and close the collecting system and renal defect. Margin sectioning and hemostasis are perfectly controlled. Clamping pressure can be progressively released to improve hemostasis before closing the renal defect. Frozen section analysis of surgical margin status can be done carefully. When using this maneuver in the initial 10 patients, we did not observe blood loss or surgical complications. A similar technique was described by Gill et al using a tourniquet,6 and by Cariou and Cussenot7 using 2 clamps. However, these techniques were essentially useful for renal pole lesions. Most small tumors for which nephron sparing surgery is indicated are peripheral on the convex line, often with extrarenal development. Selective renal parenchymal clamping is feasible using this clamp for renal tumors, provided that it widely circumscribes the tumor. The point is the size and location of the intraparenchymal portion of the neoplasm. In cases of a large central or hilar tumor, or tumor close to the pedicle it is more difficult to circumscribe the mass and the classic technique with renal artery occlusion and renal surface cooling is required. Clamping pressure must be controlled by a loop to avoid crushing the kidney. Because the rack is too short, a new clamp with a large rack is currently being manufactured to facilitate the procedure. In conclusion, selective renal parenchymal clamping is a simple and efficient technical maneuver for nephron sparing surgery in a large number of renal tumor cases that does not necessitate any specific investment. REFERENCES
1. Uzzo, R. G. and Novick, A. C.: Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol, 166: 6, 2001 2. Novick, A. C.: Partial nephrectomy for renal cell carcinoma. Urol Clin North Am, 14: 419, 1987 3. Bazeed, M. A., Scharfe, T., Becht, E. et al: Conservative surgery of renal cell carcinoma. Eur Urol, 12: 238, 1986 4. Chretien, Y., Mejean, A., Cazalaa, J. B. et al: Conservative surgical techniques in the treatment of kidney tumors. Progr Urol, 10: 134, 2000 5. Campbell, S. C., Novick, A. C., Streem, S. B. et al: Complications of nephron sparing surgery for renal tumors. J Urol, 151: 1177, 1994 6. Gill, I. S., Munch, L. C., Clayman, R. V. et al: New renal tourniquet for partial nephrectomy. J Urol, 154: 1113, 1995 7. Cariou, G. and Cussenot, O.: Haemostasis technique in partial nephrectomy. Progr Urol, 6: 605, 1996