Renal hilum approach based on R.E.N.A.L Nephrometry Score in laparoscopic partial nephrectomy. Effects on surgical time, intraoperative bleeding and surgical complications. A single-center experience
DOI:
https://doi.org/10.48193/tfcvm546Keywords:
partial nephrectomy , sschemia , RENAL score , hilum approachAbstract
Introduction: nephron-sparing surgery (NSS) has emerged as the preferred treatment for renal tumors, aiming to balance oncological outcomes and renal function preservation. Partial nephrectomy (PN) has shown comparable cancer-specific survival rates to radical nephrectomy (RN). Notably, postoperative renal damage is associated with both ischemia time and parenchymal loss, emphasizing the importance of preserving renal function during tumor resection. The R.E.N.A.L. Nephrometry Score (RNS), has enhanced the quantification of renal tumor characteristics and improved standardization, guiding surgical decisions. This study aims to describe different hilum approaches based on RNS during laparoscopic PN and analyze their impact on surgical time, intraoperative bleeding, and functional outcomes.
Methods: a retrospective analysis of 90 laparoscopic partial nephrectomy cases was conducted. Surgical time, estimated blood loss (EBL), renal hilum approach (including hilum dissection with renal artery clamping [HD&RAC], hilum dissection without renal artery clamping [HD&noRAC], and no hilum dissection with no renal artery clamping [noHD&noRAC), complication rates and RNS-guided complexity (low: RNS < 7, intermediate: RNS 7-9, high: RNS > 9) were assessed. The choice of hilum approach and abdominal access was determined by the physician based on tumor complexity assessed using RNS.
Results: surgical time varied significantly between hilum approaches, with HD&RAC being the longest (196min), followed by HD&noRAC (147min) and noHD&noRAC (130min). The mean surgical time was statistically significantly different between HD&RAC and HD&noRAC (p-value = 0.0005) and between HD&RAC and noHD&noRAC (p-value = 0.0001). Intraoperative bleeding was higher in the HD&RAC approach than the noHD&noRAC approach (p-value = 0.039). Pre- and post-surgery glomerular filtration rates did not significantly differ by hilum approach (p= 0.7255) or complexity of the renal mass (p= 0.5633). No intraoperative complications were reported. However, three patients with high RNS experienced postoperative urinary fistulas.
Conclusion: the choice of renal hilum approach significantly impacts surgical time and intraoperative bleeding during laparoscopic partial nephrectomy. Using RNS to guide the approach selection allows for optimal surgical outcomes without compromising glomerular filtration rate (GFR). Further research is needed to validate these findings in larger, multicenter studies and assess long-term outcomes associated with different hilum approaches in laparoscopic PN.
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