Nephron sparing surgery

History
1869 first planned nephrectomy by Simon (for urinary fistula) - a kidney can be
extirpated safely from a human being - a patient can survive with only one kidney
1870 partial nephrectomy by Simon for hydronephrosis 1884 Wells accidentally
removed a third of a kidney (perirenal fibrolipoma)
1887 Czerny did the first partial resection for a tumor (angiosarcoma)
1950 – Vermooten – foundation of modern nephron sparing surgery
Indications
● Initially NSS was done in patients with small renal tumors
● Now done for preservation of renal function which is critically important
● Nephron sparing surgery preserves renal function

● Indications-
Baseline CKD
Abnormal C/L kidney
Multifocal /familial RCC
Threat to future renal functions- HTN/DM/CAD/Nephrolithiasis
Nephrometry scoring systems
● In recent years, the development of new imaging techniques and scoring systems have improved
the diagnosis and management of small renal masses.
● Important role in the planning of nephron-sparing surgery,

● Provides information necessary to determine the complexity of the renal mass, to deliver the
appropriate postoperative care, and to predict adverse outcomes.

● RENAL score, PADUA score, MAP score, C index

RENAL SCORE
RENAL nephrometry score (RNS) was developed by Kutikov and Uzzo to standardize the assessment
of anatomical features of renal tumor.

The scoring system is based on the five most reproducible features that characterize the anatomy of a
solid renal mass:

● R: Radius-scores tumor size as maximal diameter

● E: Exophytic/endophytic properties of the tumor
● N: Nearness of the deepest portion of the tumor to the collecting system or renal sinus
● A: Anterior (a)/posterior (p) descriptor
● L: Location relative to the polar line.
RENAL SCORE
● Polar lines are defined as the plane of the kidney above or below which the medial lip of
parenchyma is interrupted by the renal sinus fat, vessels, or the collecting system on axial
imaging.
● All components except for the (A) descriptor are scored on a 1-, 2-, or 3-point scale.
● The (A) describes the principal mass location to the coronal plane of the kidney.
● suffix “x” - is assigned to the tumor if an anterior or posterior designation is not possible.
● suffix “h” - used to designate a hilar location of the tumor (abutting the main renal artery or
vein).
● Limitations- relation of tumor to calyceal system is not included
PADUA score
● Published by Ficarra et al in 2009
● “ Preoperative aspects and dimensions used for anatomical classification”

● All tumours were classified by integrating size with the following anatomical features:
anterior or posterior face
Longitudinal location (Upper, middle and lower)
rim tumour location (lateral and medial)
Relationship with renal sinus (without / located or extended)
Relationship with urinary collecting system (absent/present)
percentage of tumour deepening into the kidney (> 50% exophytic,
<50%exophytic, endophytic)
Maximal diameter into centimeters (4, 4.1-7, >7cm)
PADUA score
● Each parameter is scored ranging from 1 to 3
● Main difference from RENAL score is PADUA scoring divides kidney into three parts
upper, middle and lower part
Mayo Adhesive Probability (MAP) score
● Adherent perinephric fat contributes to surgical complexity and can be associated with adverse
perioperative outcomes for partial nephrectomy.
● Preoperative imaging (CT or T1-weighted MRI)
● The MAP score is calculated for each patient utilizing the measurement of posterior renal fat
thickness and the measure of severity of perinephric stranding.
● Perinephric fat thickness is measured at the level of the renal vein as a direct line from the level
of the renal capsule to the posterior abdominal wall in centimeters (<1 cm =0 points, 1.1–1.9 cm
=1 point, >2.0 cm =2 points)
● Perinephric stranding is identified as soft tissue attenuation in the fat surrounding the kidney and
graded according to severity if present (0= no stranding, 2= thin mild stranding, 3= diffuse
stranding).
● The 2 scores are combined to give a MAP score of 0-5.
Technique
● Various surgical techniques of partial nephrectomy
● The spectrum of surgical options includes

(i) tumor enucleation

(ii) polar segmental nephrectomy

(iii) wedge resection

(iv) major transverse resection, and

(v) extracorporeal partial nephrectomy with autotransplantation

Tumor enucleation
● Usually done for small tumors
● The renal cortex surrounding the tumor is marked circumferentially using electrocautery.
● The plane outside the tumor pseudocapsule and within the normal parenchyma is identified and
bluntly dissected with small closed scissors.
● For enucleation of small lesions, renal occlusion is usually not necessary.
● However, if there is excessive bleeding that hampers proper visualization of the resection
margin, then manual compression of the kidney or clamping of the renal pedicle can help.
● The tumor is excised, and the margins are examined for gross evidence of a positive surgical
margin
Segmental nephrectomy
Wedge resection
● The renal capsule is circumferentially incised 5 to 10 mm peripheral to the tumor with
electrocautery.
● Using a combination of blunt and sharp dissection with Metzenbaum scissors, the tumor is
excised with a small rim of normal parenchyma.
● Bleeding vessels are controlled with figure-of-eight sutures or or bipolar electrocautery.
● The deep resection margin of the kidney must be inspected for any residual tumor or any sign of
collecting system injury.
● If there is any doubt about collecting system injury, 10 to 20 mL of diluted indigo carmine is
injected into the renal pelvis while occluding the ureter to assess for
● leaks. The collecting system is closed with a 4-0 absorbable suture.
Technique
Technique
Warm ischaemia time
● Warm ischaemia time is usually considered as 30 minutes.
● There are three main mechanisms of ischemic renal injury, including persistent vasoconstriction
with an abnormal endothelial cell compensatory response, tubular obstruction with backflow of
urine, and reperfusion injury.

● maximal kidney tolerability to warm ischemia, which can be influenced by surgical technique,
patient age, presence of collateral vascularization, indemnity of the arterial bed, and so forth.
Hypothermia
● When the surgeon anticipates a warm ischemia time exceeding the “classical” 30 minutes, local
renal hypothermia is used to protect against ischemic renal injury.
● Hypothermia has been the most effective and universally used means of protecting the kidney
from the ischemic insult.

● Hypothermia reduces basal cell metabolism, energy-dependent metabolic activity of the cortical
cells, with a resultant decrease in both the consumption of oxygen and ATP
Hypothermia
● There are multiple ways of achieving hypothermia.
● Surrounding the fully mobilized kidney with crushed ice (ice slush) is the most frequently used
technique because of its ease and simplicity.
● When using ice slush to reduce kidney temperature, it is recommended to keep the entire kidney
covered with ice for 10 to 15 minutes immediately after occluding the renal artery and before
commencing the resection of the tumor in order to allow core renal temperature to decrease to
approximately 20 degrees centigrade or less
Ischaemia time
● Mannitol, with or without the addition of furosemide, should be administered intravenously 5 to
15 minutes before renal arterial clamping as it increases renal plasma flow, decreases intrarenal
vascular resistance and intracellular edema, and promotes an osmotic diuresis when renal
circulation is restored.
● Regular use of heparin to prevent intrarenal vascular thrombosis has not been found to be useful
● generous preoperative and intraoperative hydration, prevention of intraoperative hypotension,
avoidance of unnecessary manipulation or traction on the renal artery as well as the
aforementioned administration of mannitol are necessary to keep the kidney adequately perfused
before and after the ischemic insult.
Ischaemia time
super-selective embolisation is a valid option for partial nephrectomy

Other methods than the use of ice slush to achieve renal hypothermia have also being explored,
including

● application of ice-slurry
● antegrade perfusion of the renal artery either via preoperative renal artery catheterization
● via intraoperative renal artery cannulation
● retrograde perfusion of the collecting system with cold solutions or near-freezing saline
irrigation delivered with a standard irrigator aspirator among others
Technique
● In small and peripherally located tumours, laparoscopic partial nephrectomy can be
accomplished in the absence of hilar control by novel mechanical and biological
haemostatic aids.
● These agents are classified into:

(a) biological haemostatic agents

(b) laparoscopic dissector/coagulator instruments.

Technique
Renorhhaphy
Agarwal Sliding clip renorhhaphy
Technique
● Nephropexy should be considered if the kidney is
quite mobile; however, injury to retroperitoneal
nerves overlying the psoas and quadratus
lumborum muscles must be avoided
● The kidney is covered with perirenal fat and renal
fascia, and a closed suction drain is placed to
monitor output postoperatively.
Technique- Minimally invasive techniques
● Laparoscopic or robotic

● Advantages-

Decreased pain and morbidity

Shorter hospital stay

Improved cosmesis
Complications- Urinary Fistula
● Most urinary fistula present themselves in about 1 week postoperatively.
● Therefore, in cases of deep renal resections, it is advisable to keep the closed drain for
longer time upto 7-10 days

● Diagnosis-

confirmed by checking the effluent for creatinine

Alternatively, an intravenous ampule of indigo carmine, when injected and

collected in the closed suction drain, can also confirm the diagnosis.
Complications- Urinary Fistula
● The treatment of urinary fistulae requires three tubes:

(1) a retroperitoneal closed suction drain to collect the

urinoma
(2) a double-J ureteral stent that is placed after retrograde pyelography
(3) a Foley catheter to keep the entire collecting system at low pressure.

● Most fistulas resolve within 4 to 6 weeks with conservative management, and

reoperation is rarely required.

Complications- Postoperative Bleeding.
● Delayed bleeding can occur following partial nephrectomy, particularly in patients who require
postoperative anticoagulation therapy.
● If a drain is in place, initial management is conservative and consists of bed rest, hydration,
close clinical monitoring, and serial evaluations of blood counts.
● In situations in which more than 1 to 2 units of transfused blood products are required, renal
angioembolization should be attempted.
● Usually, bleeding segmental and subsegmental arteries can be selectively embolized and the
kidney salvaged without need for complete nephrectomy.
● Life-threatening hemorrhage can also occur and require reoperative exploration .
Complications- Renal Insufficiency
● Acute renal failure may follow partial nephrectomy in a solitary kidney, related to large size of
the tumor, excessive removal of renal parenchyma, and prolonged ischemic time.
● Obstruction of the collecting system, drug toxicity, vascular thrombosis, and vascular disruption
are other causes that should be considered.
● Although most cases of postoperative renal insufficiency are mild and temporary, some cases
require hemodialysis for electrolyte and fluid management.

● Hyperfiltration injury can also cause a gradual decrease in renal function over time, typically
associated with proteinuria.
Hyperfiltration Injury
● When a significant portion of renal parenchyma is removed, the renal blood flow is delivered to
a smaller number of nephrons, which can lead to increased glomerular capillary perfusion
pressure that results in an increased single nephron glomerular filtration rate called
hyperfiltration
● Over decades, the hyperfiltration can injure the remaining nephrons, resulting in focal segmental
glomerulosclerosis and the clinical manifestations of proteinuria and progressive renal failure

● Hyperfiltration injury is most common when the total nephron mass of both kidneys is reduced
by more than 80%.
RN was associated with an increased risk of overall mortality (hazard ratio [HR] 1.38, P<0.01) and a
1.4 times greater number of CV events after surgery (P<0.05).

RN, however, was not associated with an increased risk of time to first CV event (HR 1.21, P=0.10) or

CV death (HR 0.95, P=0.84).

Compared with partial nephrectomy, radical nephrectomy is associated with decreased overall survival
in younger patients with small renal masses.
● Systematically evaluated the impact of positive surgical margins (PSM) on oncological
outcomes after partial nephrectomy for renal cell carcinoma.
● Forty-two studies comprising 101,153 subjects were included and five distinct meta-analyses
were performed.
● Positive surgical margin was associated with increased risk of local recurrence
● Patients with positive surgical margin should be counseled for the possibility of additional
surgery, novel adjuvant therapies, and more rigorous surveillance.