Nephron-sparing algorithm for minimally invasive partial nephrectomy

Introduction. Partial nephrectomy is the gold‑standard treatment for localised renal cell carcinoma. Further gains in outcomes after nephron‑sparing surgery require a shift in treatment strategy, with management centred on optimising the technique of partial nephrectomy so as to preserve the greatest possible number of functioning nephrons.

Objective. To develop an in-practice algorithm for robot‑assisted nephron‑sparing partial nephrectomy and to report early clinical outcomes following its implementation.

Materials & methods. We outline the core principles underpinning nephron‑sparing surgery and provide a detailed, stepwise description of the operative workflow for partial nephrectomy. Technical considerations are discussed in relation to case complexity. We reviewed the first 100 nephron‑sparing procedures performed at the Botkin Moscow Multidisciplinary Clinical Research Centre between 2020 and 2021 (70 laparoscopic and 30 robot‑assisted partial nephrectomies) within a prospective cohort, with renal functional outcomes assessed at one year postoperatively.

Results. Preoperatively, most patients had clinical stage cT1a disease (n=70), with cT1b (n=14) and cT2 (n=4) tumours comprising the remainder; cystic renal lesions were present in 12 patients. Warm ischaemia was applied in 14% of cases, with a mean duration of 9 minutes and a maximum duration of 25 minutes. The negative surgical margin rate was 97%. Trifecta outcomes were achieved in 89% of patients, while Pentafecta criteria were met in 55%.

Conclusion. Adherence to nephron‑sparing surgical principles can enhance functional outcomes following organ‑preserving renal surgery. The detailed operative algorithm presented here may be particularly useful when establishing a minimally invasive partial nephrectomy programme.

1. Gill IS, Matin SF, Desai MM, Kaouk JH, Steinberg A, Mascha E, Thornton J, Sherief MH, Strzempkowski B, Novick AC. Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients. J Urol. 2003;170(1):64-68. DOI: 10.1097/01.ju.0000072272.02322.ff

2. Cozar JM, Tallada M. Open partial nephrectomy in renal cancer: a feasible gold standard technique in all hospitals. Adv Urol. 2008;2008:916463. DOI: 10.1155/2008/916463

3. Matveev V.B., Matveev B.P., Volkova M.I., Perlin D.V., Figurin K.M. Contemporary roll of organ-preserving surgery of renal cell carcinoma. Cancer Urology. 2007;3(2):5-11. (In Russian). DOI: 10.17650/1726-9776-2007-0-2-5-11

4. Ljungberg B, Albiges L, Abu-Ghanem Y, Bedke J, Capitanio U, Dabestani S, Fernández-Pello S, Giles RH, Hofmann F, Hora M, Klatte T, Kuusk T, Lam TB, Marconi L, Powles T, Tahbaz R, Volpe A, Bex A. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 Update. Eur Urol. 2022;82(4):399-410. DOI: 10.1016/j.eururo.2022.03.006

5. Campbell S, Uzzo RG, Allaf ME, Bass EB, Cadeddu JA, Chang A, Clark PE, Davis BJ, Derweesh IH, Giambarresi L, Gervais DA, Hu SL, Lane BR, Leibovich BC, Pierorazio PM. Renal Mass and Localized Renal Cancer: AUA Guideline. J Urol. 2017;198(3):520-529. DOI: 10.1016/j.juro.2017.04.100

6. Seregin А.А., Seregin А.V., Kolontarev K.B., Shustitskiy N.A., Chekhonatskiy I.A., Loran О.B. Preoperative factors affecting a rate of trifecta and pentafecta achievement after partial nephrectomy. Urologiia. 2023;(5):57-62. (In Russian). DOI: 10.18565/urology.2023.5.57-62

7. Antonelli A, Cindolo L, Sandri M, Veccia A, Annino F, Bertagna F, Carini M, Celia A, D’Orta C, De Concilio B, Furlan M, Giommoni V, Ingrosso , Mari A, Nucciotti R, Olianti C, Porreca A, Primiceri G, Schips L, Sessa F, Bove P, Simeone C, Minervini A; AGILE Group (Italian Group for Advanced Laparo-Endoscopic Surgery). Is off-clamp robot-assisted partial nephrectomy beneficial for renal function? Data from the CLOCK trial. BJU Int. 2022;129(2):217-224. DOI: 10.1111/bju.15503

8. Lane BR, Campbell SC, Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol. 2013;190(1):44-49. DOI: 10.1016/j.juro.2012.12.102

9. Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR Jr, Frank I, Permpongkosol S, Weight CJ, Kaouk JH, Kattan MW, Novick AC. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol. 2007;178(1):41-46. DOI: 10.1016/j.juro.2007.03.038

10. Indarokov T.R., Seregin A.V., Loran O.B., Shustickiy N.A., Simankov I.V., Bessolova O.V., Jandiev A.M. Evaluation of renal function after partial nephrectomy for cancer. Consilium Medicum. 2017;19(7):23-27. (In Russian). DOI: 10.26442/2075-1753_19.7.23-27

11. Perlin D.V., Alexandrov I.V., Zipunnikov V.P., Kargin K.A. Laparoscopic partial nephrectomy using local ischemia. Urologiia. 2013;(4):69-73. (In Russian). eLIBRARY ID: 20589115; EDN: RIOISJ

12. Perlin DV, Sapozhnikov AD, Zipunnikov VP, Lyaluev AM, Shevchenko ON. Organ-preserving laparoscopic surgeries for renal cancer with the use of segment-by-segment ischemia. Endoscopic Surgery. 2014;20(6):9 13. (In Russian). DOI: 10.17116/endoskop201469-13

13. Sirota E.S., Rapoport L.M., Gridin V.N., Tsarichenko D.G., Kuznetsov I.A., Sirota A.E., Alyaev Yu.G. Analysis of the learning curve in laparoscopic partial nephrectomy in patients with localized renal parenchymal lesions depending on the nephrometric score. Urologiia. 2020;(6):11-18. (In Russian). DOI: 10.18565/urology.2020.6.11-18.

14. Proskura A.V., Alyaev Yu.G., Borisov V.V., Butnaru D.V., Rapoport L.M., Sirota E.S., Suvorov A.Yu., Fiev D.N., Shpot E.V., Bezrukov E.A., Enikeev M.E., Akopyan G.N., Korolev D.O., Vorobiev A.A., Chernenkiy M.M., Chernenkiy I.M., Ismailov Kh.M., Shomukimova Z.S. Assessment of the kidney functional state prior and after partial nephrectomy for a unilateral tumor using mathematical processing of computed tomography data with contrast enhancement. Andrology and Genital Surgery. 2023;24(3):66-74. (In Russian). DOI: 10.17650/2070-9781-2023-24-3-66-74

15. Alyaev Yu.G., Sirota E.S., Rapoport L.M., Bezrukov E.A., Sukhanov R.B., Tsarichenko D.G. Comparison of the significance of the RENAL, PADUA, and C-index nephrometric scales for the prediction of the complexity of laparoscopic nephrectomy. Cancer Urology. 2018;14(1):36-46. (In Russian). DOI: 10.17650/1726-9776-2018-14-1-36-46

16. Shpot E.V., Mamedkasimov N.A., Alyaev Y.G., Rapoport L.M., Proskura A.V., Mashin G.A. A comparative analysis of laparoscopic and retroperitoneoscopic partial nephrectomy depending on the type of temporary and definite hemostasis. Urologiia. 2018;(6):95-100. (In Russian). DOI: 10.18565/urology.2018.6.95-100

17. Glybochko P.V., Alyaev Y.G., Pshikhachev A.M., Shpot’ E.V., Sorokin N.I., Dymov A.M., Akopyan G.N., Chinenov D.V., Snurnitsyna O.V. The potential of endovideosurgical technologies for simultaneous ipsilateral presentation of a kidney tumor and kidney stone. Urologiia. 2016;(3):70-75. (In Russian).

18. Alyaev Yu.G., Bezrukov E.A., Sirota E.S., Shpot E.V., Proskura A.V. Methods of hemostasis in laparoscopic partial nephrectomy. Urologiia. 2014;(4):90-95. (In Russian).

19. Mamedkasimov N.A., Spot E.V., Alyaev Y.G., Rapoport L.M., Sorokin N.I. Zero-ischemia nephron-sparing interventions for renal tumor. do we need 3D-modeling? Urologiia. 2019;(1):56-62. (In Russian). DOI: 10.18565/urology.2019.16.56-62

20. Kotov S.V., Guspanov R.I., Yusufov A.G., Nemenov A.A., Mantsov A.A. Effect of adherent perinephric fat on outcomes of nephron-sparing treatment of renal cell cancer. Urology Herald. 2023;11(2):47-55. (In Russian). DOI: 10.21886/2308-6424-2023-11-2-47-55

21. Kochkin A.D., Knutov A.V., Sevryukov F.A. Laparoscopic partial nephrectomy for kidney tumors R.E.N.A.L. score 10 & higher. Urologiia. 2020;(6):93-98. (In Russian). DOI: 10.18565/urology.2020.6.93-98

22. Kotov S.V., Nemenov A.A., Yusufov A.G., Guspanov R.I., Pulbere S.A., Prostomolotov A.O. Comparison of perioperative and short-term functional outcomes of laparoscopic partial nephrectomy in patients with cT1aN0M0 and cT1b-T2aN0M0 tumors. Cancer Urology. 2021;17(4):38- 46. (In Russian). DOI: 10.17650/1726-9776-2021-17-4-38-46

23. Nosov A.K., Lushina P.A., Petrov S.B. Laparoskokpicheskaya rezekciya pochki bez ishemii i bez nalozheniya gemostaticheskogo shva na zonu rezekcii u pacientovs rakom pochki. Urologicheskie vedomosti. 2016;6(S):76-77. (In Russian). eLIBRARY ID: 26291166; EDN: WDIOOX

24. Popov S.V., Zaytsev E.V., Petrova Y.A., Guseynov R.G., Topuzov T.M. Evaluation of different methods of hemostasis when performing laparoscopic partial nephrectomy. Urologiia. 2013;(3):61-67. (In Russian).

25. Петров С.Б., Шпиленя Е.С., Шкарупа Д.Д. Функциональные результаты резекции почки при новообразованиях. Вестник хирургии им. И.И. Грекова. 2009;168(4):85-87. Petrov S.B., Shpilenya E.S., Shkarupa D.D. Functional results of partial nephrectomy for kidney tumors. Grekov’s bulletin of surgery. 2009;168(4):85-87. (In Russian). eLIBRARY ID: 13055660; EDN: KZSDBR

26. Nosov A.K., Mamizhev E.M., Shchekuteev N.A., Semeyko D.P., Lushina P.A., Rumyantseva D.I., Berkut M.V. Techniques of surgical hemostasis and sealing after laparoscopic partial nephrectomy. Cancer Urology. 2022;18(3):27-34. (In Russian). DOI: 10.17650/1726-9776-2022-18-3-27-34

27. Seregin A.A., Seregin A.V., Kolontarev K.B., Seregin I.V., Makhmadaliev A.I., Loran O.B. Preventive sutures in nonischemic laparoscopic partial nephrectomy. Description of S.P. Botkin City Clinical Hospital technique. Cancer Urology. 2022;18(3):35-40. (In Russian). DOI: 10.17650/1726-9776-2022-18-3-35-40

28. Seregin A.V., Shustitskiy N.A., Indarokov T.R., Morozov A.D., Bessolova O.V. Partial nephrectomy using preventive hemostatic sutures in renal cell carcinoma patients. Annals of Surgery. 2016;21(4):235-239. (In Russian). eLIBRARY ID: 26555246; EDN: WJCVCD

29. Seregin A., Seregin I., Makhmadaliev A. 3D laparoscopy for partial nephrectomy: first application experienceand preliminary results. Meditsinskii vestnik MVD. 2022;121(6):34. (In Russian). eLIBRARY ID: 49828234; EDN: RHJHTI

30. Seregin A.V., Loran O.B., Seregin A.A., Shustitskiy N.A., Seregin I.V., Bessolova O.V., Indarokov T.R. Possibilities and features of zero-ischemia nephron-sparing surgery in localized kidney cancer. Urology Herald. 2023;11(2):188-202. (In Russian) DOI: 10.21886/2308-6424-2023-11-2-188-202