Author
Year
Cases
Complication rate (%)
Timing of the complication
Bleeding (%)
Urine leak (%)
Other
Intra-operative
Post- operative
Gettman [3]
2004
13
2 (8%)
0
1
0 (%)
0 (0%)
1
Caruso [4]
2006
10
3 (30%)
2
1
2 (20%)
0 (0%)
2
Kaul [5]
2007
10
2 (20%)
n/a
n/a
1 (10%)
1 (10%)
0
Aron [6]
2008
12
4 (33%)
1
3
0 (0%)
0 (0%)
4
Deane [7]
2008
11
1 (9%)
0
1
1 (9%)
0 (0%)
0
Rogers [8]
2008
11
2 (18%)
0
2
0 (0%)
2 (18%)
0
Rogers [9]
2008
148
9 (6.1%)
0
9
1 (0.6%)
2 (1.2%)
6
Wang [10]
2009
40
8 (20%)
n/a
n/a
3 (7.5%)
1 (2.5%)
4
Michli [11]
2009
20
3 (15%)
1
2
0 (0%)
0 (0%)
0
Ho [12]
2009
20
0 (0%)
0
0
0 (0%)
0 (0%)
0
Benway [13]
2009
129
11 (8.5%)
n/a
n/a
4 (3%)
3 (2.3%)
4
Patel [14]
2010
71
10 (14%)
1
9
4 (5.6%)
2 (3%)
4
Scoll [15]
2010
100
5 (5%)
n/a
n/a
0 (0%)
2 (2%)
3
Petros [16]
2010
83
5 (8%)
0
5
1 (1.2%)
2 (2.4%)
2
Ficarra [17]
2012
49
15 (26%)
2
13
n/a
n/a
n/a
Gupta [18]
2013
17
1 (6%)
0
1
0
1
0
Overall, the prevention of complications begins with a detailed understanding of important landmarks and meticulous surgical planning. This is best achieved by a CT scan-based evaluation of renal, tumor and renovascular anatomy by the surgeon. In this context, we believe that the image quality afforded by a renal protocol CT scan is superior to MRI scan. At our institution, we use 0.5–1 mm slice-thickness CT scan images, with oral and intravenous contrast. Arterial, parenchymal, venous and excretory (delay) phases are generated for evaluation. Consultation with specialized uro-radiologist is advisable for detailed imaging interpretation. If available, a 3D reconstruction of the tumor, intra-renal arterial tree and kidney, and 3D–printed models can facilitate better 3D understanding of the anatomy [20, 21].
Important information for PN surgery is as follows:
Patient characteristics: body habitus; body mass index, perinephric fat measurements and adhesiveness.
Renal vessels: number of arteries and veins, arterial tree branching, tumor-feeding arteries, relation between the tumor, renal artery and renal vein.
Tumor: size, clinical stage, location (anterior, posterior, lateral), relation to polar lines (upper, mid or lower pole), endophytic/exophytic ratio, proximity to the hilum, closeness to collecting system, tumor contact surface area (CSA).
Collecting system: ureteral course, endophytic/exophytic ratio of the renal pelvis.
Understanding the relationship of the kidney and its vasculature with: duodenum, vena cava, hepato-duodenal ligament and liver for right-sided RPN; and with the aorta, lumbar veins, renal vein tributaries (adrenal and gonadal veins), superior mesenteric artery, splenic vessels, spleen, pancreas and stomach for left-sided RPN.
Nephrometry scoring systems such as R.E.N.A.L [22], PADUA [23], Renal Tumor Contact Surface Area (CSA) [24], C-Index [25], Adhesive Probability Score [26], Renal Pelvic Score [27] are useful tools for precise anatomic understanding and sophisticated surgical pre-planning for PN based on individualized, patient-specific data. This helps to predict and minimize complications related to PN surgery (Table 18.2). Nomograms are also available: http://lbs.fccc.edu/nomograms/main.php?nav=3&audience=1
Table 18.2
Nephrometric score and complication rate
Nephreometric score | Parameter analized | Grade | Overall complications (%) |
|---|---|---|---|
Radius (max diameter in cm), Exophytic/endophytic properties, Nearness to the collecting system, Anterior/posterior, Location relative to the polar line | Low complexity | 3.4% | |
Moderate complexity | 5.4% | ||
High complexity | 15.9% | ||
P.A.D.U.A. [23] | Radius (max diameter in cm) Exophytic/endophytic Location, sinus line Renal rim Renal sinus Collecting system | Anterior low (6–7) | 2.0% |
Anterior Moderate (8–9) | 40.0% | ||
Anterior ≥ High (≥ 10) | 50.0% | ||
Posterior low (6–7) | 5.6% | ||
Posterior moderate (8–9) | 32.0% | ||
Posterior ≥ High (≥ 10) | 61.5% | ||
Tumor centrality | Low (score 2.5 or greater) | 14.7% | |
High (score less than 2.5) | 29.0% | ||
Contact surface area [24] | Tumor-parenchyma contact Surface area | <20 cm2 | 19.2% |
≥20 cm2 | 34.5% | ||
Adhesive Perinephric Fat (APF) score [26] | Presence of APF | None stranding (0 pt) | n/a |
Mild/Moderate stranding (2 pt) | n/a | ||
Severe stranding (3 pt) | n/a | ||
Renal pelvic score [27] | Morphology of renal pelvis | Intraparenchimal | 75% (urine leak) |
Extraparenchimal | 6.5% (urine leak) |
Intraoperative Bleeding and Vascular Injury
Intraoperative bleeding can originate from the PN resection bed, renal hilar vessels, lumar veins, or rarely, from vena cava or aorta.
How to Prevent Intraoperative Reno-Vascular Bleeding
As already discussed, understanding the inter-relationships of the tumor vis-à-vis renovascular anatomy is crucial for uneventful RPN. Firstly, wide medial mobilization of the colon (and duodenum for right-sided tumors) to complete expose the kidney, identification of the renal artery and vein and their tributaries (and vena cava for right-sided tumors) is mandatory. The ureter should be identified and retracted laterally by the robotic fourth arm, and the psoas muscle is identified posteriorly. The ureter and the kidney are then retracted laterally. Dissection towards to the hilum is performed from distally to proximal. The renal vein and renal artery are dissected and vessel loops applied. Careful dissection of the tissue in layers is advised.
How to Manage Intraoperative Reno-Vascular Bleeding
It is important to keep calm, communicate with the operative team and anesthesiologist, call for any needed assistance, and ensure blood is available for transfusions, if necessary. The surgeon needs to expeditiously make a decision whether he/she has the necessary skill-level and experience to control the bleeding robotically, or whether open conversion is necessary. Remember: open conversion is NEVER a surgical “defeat”, rather it is the smart and responsible decision to ensure patient safety, which must always be the paramount consideration. Increase the pneumo-peritoneum to 20 mmHg. Insert a mini-lap sponge (4″ × 18″ dimension) to compress the bleeding site. Suctioning should be judicious to clear the field, and also to compress the site. Change instruments for graspers and/or needle-drivers, as soon as possible, if necessary. Place additional ports if needed. After identification of the bleeding site, it should be controlled by applying weck clips or suturing. A critical maneuver in this regard is having a “rescue stitch” always ready on the back-table for prompt management of hemorrhage. The “rescue stitch” is a 15 cm long (6″), 2.0 Vicryl® suture on a CT 1 needle, with Hem-0-lock® clip tied to its end [30]. This stich is easy to handle, as it is malleable (does not have “memory”) and the weck clip tied to the end allows for knotless bleeding control by merely pulling on the stitch.
How to Prevent PN Resection Bed Bleeding
Different factors impact PN resection bed bleeding such as: mass diameter, depth of penetration in the renal parenchyma and tumor contact surface area [31]. To prevent this complication it is important to:
Obtain an adequate understanding of the renal mass characteristics as pointed previously.
Have renal vessels accessible, ideally with vessel loops, for (re)clamping
Mobilize the kidney properly. During PN surgery, “always mobilize the kidney more than you think it would be necessary”, especially for posterior or upper pole tumors.
First clamp the renal artery, then the renal vein.
Consider using infra-red “Firefly” technology to ensure lack of perfusion to the kidney or to the area of interest, in case of selective/superselective clamping [32].
Keep the field clean to allow for good visualization during tumor resection, therefore, if larger vessels from the renal sinus are encountered they can be pre-clipped prior to transecting.
Start suturing the inner layer of the PN defect during the reconstruction/hemostasis. This step is very import to prevent bleeding from deep, therefore difficult to reassess, resection site after the clamp is released. There are many ways to suture the PN resection bed. We prefer the horizontal mattress suture technique, which hemostatically compresses the PN bed, without closing it over, thereby still allowing excellent visualization of the entire PN bed at all times. Usually 1–2 mattress layers are used for hemostasis prior to unclamping.
“Early-unclamping” technique. Besides the advantage of reducing warm ischemia time (WIT), the early-unclamping technique (first renal vein, then renal artery) provides direct visualization of any residual bleeding, which can then be pin-point sutured-controlled.
To physically clear the PN resection bed of any overlying blood clots and to identify any residual parenchymal bleeders, we recommend strong irrigation rather than suctioning; the latter can cause parenchymal abrasions leading to additional oozing. .Related posts:
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