Hand-assisted laparoscopic partial nephrectomy elimintes collection-system suturing

Lexington, KY-Laparoscopic partial nephrectomy without collection-system suturing led to a urine leak rate comparable to that of procedures with formal collection-system closure, researchers from the University of Kentucky, Lexington reported.

Urine leakage occurred in three of 102 simplified procedures, half of which involved entry into the collecting system or hilar fat, said first author Jason R. Bylund, MD, a surgery resident working with Stephen E. Strup, MD, and colleagues.

Eliminating complex suturing could lead to increased use of laparoscopic partial nephrectomy for treatment of kidney cancer.

No catheters, stents required

Laparoscopic partial nephrectomy with suturing of the collecting system is technically challenging, limiting its use by urologic surgeons. Dr. Bylund and colleagues use a hand-assisted technique that has evolved to include routine clamping of the hilum and use of a fibrin glue patch and simple bolstering sutures without formal collection-system closure.

After isolating the tumor and mobilizing the kidney, surgeons use scissors and ultrasonic shears to resect the mass and argon-beam electrocautery to seal the parenchymal edge. They routinely resect into the hilar fat for all but the most exophytic lesions. A fibrinogen-soaked gelatin sponge is placed in the surgical defect and activated with thrombin.

"No ureteral catheters are placed," Dr. Bylund said. "No attempt is made to suture the collecting system, even when it has clearly been entered during resection of the tumor."

The review included 102 patients who had tumors that averaged 2.8 cm. Operative time averaged 189.5 minutes, and warm ischemia time for resection of a single lesion averaged 24.5 minutes with hilar clamping. Five patients required transfusions, and estimated blood loss averaged 224 mL.

Serum creatinine was measured prior to drain removal, and a leak was defined as elevated creatinine at discharge.

The three urine leaks translated into a rate of 2.9%. All three leaks resolved with conservative management, and none required ureteral stenting.

Operative reports documented entry into the collecting system or hilar fat in 52 of 102 patients, including the three who developed urine leaks. No patient lost kidney function.