[Zero-ischemia nephron-sparing interventions for renal tumor. do we need 3D-modeling?]

INTRODUCTION: our aim was to assess and compare a zero ischemia enucleation and enucleoresection of tumor, as well as classical partial nephrectomy. In addition, we defined a role of a three-dimensional reconstruction of the tumor for the planning of intervention. MATERIALS AND METHODS: a total of 83 patients with localized renal tumors were included in the study. There were 48 men (57.8%) and 35 women (42.2%), with mean age 56.8+/-11.9 years. The patients were divided into 3 groups depending on the type of intervention. The enucleation, enucleoresetion and classical partial nephrectomy with removal of 0.5-1 cm margin of normal parenchyma was performed in Group 1 (n=41), Group 2 (n=31) and Group 3 (n=11), respectively. A computer program Amira was used for the reconstruction of 3D-model of tumor during preoperative planning. On the basis of 3D-model, an information about the structures situated beneath the tumor was obtained, as well as anatomy of vessels and relationship between the renal pelvis system and the tumor. RESULTS: In all cases the interventions were performed laparoscopically. Transperitoneal access was used in 34 (41%) cases, while retroperitoneal access was chosen in 49 patients (59%). The amount of blood loss was higher in 23 patients (27.7%) with tumors located in renal sinus (205.7+/-29.1 ml), than in patients with exophytic and endophytic tumors (142.3+/-15.2 and 208.2+/-35.9 ml, respectively; p=0.005). The duration of the surgery was less in those cases where parenchyma was under the bottom of the tumor, according to the 3D-model (58.3+/-6.8 min), compared to the patients with collecting system or vessels located under the tumor (87,6+/-5.2 min, p=0.005). The amount of blood loss was 179.4 +/- 41.8 ml in patients with one vessel located beneath the tumor, according to the 3D-model, in comparison with those cases with three vessels (360.0+/-87.2 ml). There was no need for clamping of the renal vessels or conversion to the open surgery. In the enucleation group, neither intraoperative nor postoperative complications were observed. CONCLUSION: According to the results, we can conclude that 3D modeling undoubtedly gives clear advantages for the urologist during the planning of the intervention. Tumor enucleation seems to be the optimal method of partial nephrectomy, which allows to perform a dissection near to the renal sinus with the small risk of complications.

[A comparative analysis of laparoscopic and retroperitoneoscopic partial nephrectomy depending on the type of temporary and definite hemostasis].

AIM: to carry out a comparative analysis of treatment results of patients with renal tumors who were undergone to nephron-sparing surgery, depending on the type of temporary and definite hemostasis. MATERIALS AND METHODS: a total of 163 laparoscopic partial nephrectomies were performed by single surgeon from January 2015 to July 2018. The comparative analysis of treatment results of patients with renal tumors based on following parameters: tumor stage, features of the tumor site, the duration of surgery, the amount of blood loss, complications rate and grade as well as functional and oncological outcomes, depending on the type of temporary and definite hemostasis, was conducted. For preoperative planning the generally accepted nephrometric scale R.E.N.A.L. was used as well as 3D-reconstruction of the tumor. RESULTS: Of the 163 patients, 64 were women (39.3%). The mean age of patients was 56.7+/-11.1 (25-80 years). A clinical stage T1a, T1b, T2 and T3a was diagnosed in 77, 20, 2 and 64 cases, respectively. The average tumor size was 34.8+/-1.1 (11-78 mm). The mean operative time was 84.5+/-32.2 min (30-180). Laparoscopic transperitoneal access was used in 90 patients (55.21%), retroperitoneoscopic approach was chosen in 73 cases (44.79%). The tumor had exophytic growth in 110 cases (67.5%) and in 53 cases it was endophytic (32.5%), while in 59 cases it localized in renal sinus (36.2%). The operative time was significantly shorter in the Group of zero ischemia (72.2+/-29.02 [p<0.001]) and bipolar coagulation of the tumor bed (60.8+/-31.7 [p<0.001]). The mean volume of blood loss was 160.8+/-142.7 ml (30-900). A GFR calculated by the MDRD equation (mean level was 75.7 ml/min/1.73 m2) on the next day and 6 months after surgery showed a slight decrease in group of zero ischemia, compared to other groups: next day and 6 months after surgery it was 72.8+/-21.6 (p<0.001) and 72.01+/-16.6 (p=0.025), respectively. A simple enucleation was performed in 41 cases, while enucleoresection was done in 70 cases. A collection system was opened in 22 cases (13.5%+/-9.8). The suturing and clipping were performed in 20 and 2 patients, respectively. In 2 cases a stenting was performed. In 2 cases there was hemoglobin drop requiring blood transfusion (1.2%+/-3). An embolization due to refractory bleeding was required in 3 cases (1.8%+/-3.7). There was no conversion to open surgery or nephrectomy. Of the 163 tumors, a malignancy was diagnosed in 151 (92.6%+/-7.5) cases. There was no positive surgical margin and recurrence of the tumor. CONCLUSION: Laparoscopic partial nephrectomy can be successfully performed under zero ischemia. The intervention without clamping of renal blood vessels contributes to significant preservation of the renal function.