Clampless laparoscopic partial nephrectomy versus laparoscopic radical nephrectomy: a challenge in transfusion in our 9 – year experience
Laparoscopic partial nephrectomy is indicated for the treatment of small renal tumors due to its miniinvasiveness and good results in matter of nephron sparing using "zero-ischemia" technique, with the aim of completely eliminate surgical renal ischemia (1-2)
Aim of the study is evaluating the incidence of blood transfusion in comparing laparoscopic radical versus partial nephrectomy, in order to propose the technical feasibility and safety of partial procedures
Materials and Methods
Clampless laparoscopic partial nephrectomy (cl-LPN) technique was performed with no selective branch micro-dissection of renal artery/vein, and no calibrated and timed intraoperative controlled hypotension . No intraoperative controlled hypotension was performed during laparoscopic radical nephrectomy (LRN). Match analysis between surgical and transfusional data was performed . We evaluated retrospectively 147 clampless laparoscopic partial nephrectomies (cl-LPN) versus 247 laparocopic radical nephrectomies (LRN ) performed from genuary 2008 till december 2016 Patients aged 23 – 87 and 31 – 91 years for cl-LPN and LRN respectively
13 pat out of 147 clampless laparoscopic partial nephrectomies (8,8 %) versus 27 pat out of 247 (10,9%) LRN needed blood transfusions during hospitalization : 4 out of 13 (30 %) transfusion of the cl-LPN were performed after the early 12 hours postsurgery versus 6 /27 (22 %) of the radical nephrectomies: no statistically significant difference was noted between the two groups . Otherwise a statistically significant difference was noted in the need of blood transfusion between cl-LPN undergone before 2010 versus those after 2010 : 7/36 (19.4 %) versus 6 /111 (5.4 %) respectively (p< 0.05)
Clampless laparoscopic partial nephrectomy had the same incidence of transfusion as the radical ones. Our data underlined that there is no increased risk of bleeding using laparoscopic partial technique versus laparoscopic radical technique. Technical approach is very different and quite opposite: in radical procedures first of all renal vessels were identificated isolated clamped and cut ; in the partial technique first of all the renal lesion is identificated isolated and enucleated: no preventive dissection of the renal hilum was usually performed , unless in case of renal lesion located near the hilum itself. As paradox, manteining an adequate blodd pressure during surgery permits a better evaluation of blood loss in order to perform the best coagulation with bi-polar forceps, after the cold enucleation of the lesion by the scissors .
Furthermore we had to consider that 30 % of the cl-LPN and 22 % of LRN were delayied transfusion 12 hours after surgery, demonstrating only a mild vascular leakage without the need of a surgical second look
If LRN can be considered a relatively “blood sparing” safe procedure, the same we can affirm for clampless laparoscopic partial nephrectomy . A progressive decrease of the need of transfusion was noted during the observed period : this can be due both to the increasing ability of the surgeon and in the use of different hemostatic agent
Clampless laparoscopic partial nephrectomy is a feasible technique in neprhon sparing and even in “blood sparing” purpose , avoiding renal functional damage due to ischemia
1) Clampless laparoscopic partial nephrectomy: a step towards a harmless nephron-sparing surgery?
F. Porpiglia; R. Bertolo; I. Morra; C. Fiori
Int. braz j urol. vol.38 no.4 Rio de Janeiro July/Aug. 2012
2) Indications, Techniques, Outcomes, and Limitations for Minimally Ischemic and Off-clamp Partial Nephrectomy: A Systematic Review of the Literature
G. Simone , I. S. Gill , A. Mottrie, A. Kutikov , J. J. Patard , A. Alcaraz , C. G. Rogers
EUR UROL 6 8 ( 2 0 1 5 ) 6 3 2 – 6 4 0