12. HISTORY
• The first partial nephrectomy was performed in 1884
by Wells for removal of a perirenal fibrolipoma
• In 1887, Czerny was the first to use partial
nephrectomy for excision of a renal neoplasm
13. DEFINITION
Complete local resection of diseased renal
parenchyma leaving the largest possible
amount of normal functioning parenchyma in
the involved kidney
14.
15. SURGICAL TECHNIQUE
Anatomic Considerations-
Renal Arterial anatomy
• The kidney has four constant vascular segments,
which are termed apical, anterior, posterior, and
basilar
• Each of these segments is supplied by one or more
major arterial branches
• Although the origin of the branches supplying these
segments may vary, the anatomic position of the
segments is constant
• All segmental arteries are end arteries with no
collateral circulation; therefore, all branches
supplying tumor-free parenchyma must be
preserved to avoid devitalization of functioning
renal tissue.
16. • The posterior segmental artery-
supply entire posterior segment,
involving all of the posterior
portion of the kidney except that
taken up by the polar segments
• The posterior segmental artery
crosses behind the upper portion
of the pelvis at a point very close
to the origin of the superior
calyx[site of injury during mid-
kidney and lower-pole
resection]
17. • The renal venous drainage system differs
significantly from the arterial blood supply in
that the intrarenal venous branches
intercommunicate freely between the various
renal segments
• Ligation of a branch of the renal vein, will not
result in segmental infarction of the kidney
because collateral venous blood supply
• This is important clinically because it enables to
obtain surgical access safely to tumors in the
renal hilus by ligating and dividing small
adjacent or overlying venous branches.
• A true avascular line-BRODEL- exists at the
junction of the anterior and posterior
segments on the posterior surface of the
kidney.
Renal venous anatomy
18. Intrarenal collecting system
• There are 8 to 10 major calyces that
open into the renal pelvis
• apical segment- one major calyx -
receives two minor calyces[lateral and
medial]
• basilar segment- one major calyx-
receives two minor calyces[anterior
and posterior]
• anterior segment-three major calyces
which enter the renal pelvis at a 20-
degree angle to the midfrontal plane
• posterior segment-three major calyces
which enter the renal pelvis at a 75-
degree angle to the midfrontal plane
19. INTRAOPERATIVE RENAL ISCHEMIA
• Temporary occlusion of the renal artery is
necessary in NSS
• Temporary arterial occlusion not only diminishes
intraoperative renal bleeding but also improves
access to intrarenal structures by causing the
kidney to contract and by reducing renal tissue
turgor
20. • Renal artery occlusion cause reductions in
medullary blood flow with reduction in oxygen
delivery to the tubular structures
• This will lead to cellular injury due to imbalance
between oxygen delivery and demand
• Endothelial injury due to leukocyte
activation[cytokines, chemokines, eicosanoids]
and release of vasoactive substances >>
swelling and injury of the endothelial cell
21. Renal Tolerance to Warm Ischemia
• The extent of renal damage after normothermic arterial
occlusion depends on the duration of the ischemic insult
• The warm ischemic time is 30 minutes
• If it beyond 30 minutes, the recovery of renal function is either
incomplete or absent
• It affects mostly the proximal tubular cells,whereas the
glomeruli and blood vessels are generally spared
• The solitary kidney is more resistant to ischemic damage than the
paired kidney
• Presence of an extensive collateral vascular supply increases the
tolerance to temporary arterial occlusion
22. • The method employed to achieve vascular control
of the kidney is the important determinant of
renal ischemic damage
• The impairment is least when the renal artery
alone is continuously occluded
• Continuous occlusion of the renal artery and vein
for an equivalent time interval is more
damaging,because it prevents retrograde
perfusion of the kidney through the renal vein and
may also produce venous congestion of the kidney
• Intermittent clamping of the renal artery is also
more damaging than continuous arterial
occlusion,because of the release and trapping of
vasoconstrictor agents within the kidney
• Manual renal compression to control
intraoperative hemorrhage is more deleterious
than simple arterial occlusion
23. Prevention of Ischemic Renal
Damage
General measures
• Preoperative and intraoperative hydration
• Prevention of hypotension
• Avoidance of unnecessary manipulation or traction on
the renal artery
• Intraoperative administration of mannitol
These factors ensure optimal perfusion with an absence
of cortical vasospasm at the time of arterial occlusion,
which allows uniform restoration of blood flow
throughout the kidney when the renal artery is
unclamped
24. • Mannitol is most effective when it is given 5 to 15 minutes before
arterial occlusion (20%-1mg/kg)
• It increases renal plasma flow, decreases intrarenal vascular
resistance, minimizes intracellular edema, and promotes an
osmotic diuresis when renal circulation is restored
Protective measures
• Local hypothermia is the most effective and commonly employed
method
• Lowering renal temperature reduces energy-dependent
metabolic activity of the cortical cells, with a resultant decrease
in both the consumption of oxygen and the breakdown of
adenosine triphosphate
• The optimum temperature for hypothermic in situ renal
preservation is 15°C
25. It is difficult to achieve uniform cooling to this level
[15`C] because of the temperature of adjacent
tissues and need to exposed a portion of the
kidney to perform the operation
The temperature of 20°C to 25°C is easier to
maintain with renal preservative effect
This level of hypothermia provides complete renal
protection from arterial occlusion of up to 3
hours
26. In situ renal hypothermia
– External surface cooling
– Perfusion of the kidney with a cold solution instilled
into the renal artery[invasive]
• These two methods are equally effective
• Surface cooling of the kidney is a simpler and
widely used method
• surrounding the kidney with a cold solution [or]
applying an external cooling device to the kidney
27. Ice-slush cooling
• The mobilized kidney is surrounded
with a rubber sheet on which
sterile ice slush is placed to
completely immerse the kidney
• This method is to keep the entire
kidney covered with ice for 10 to
15 minutes immediately after the
renal artery is occluded
• This amount of time is needed to
obtain core renal cooling to a
temperature of 20°C
• Extent up to 2- 4 hrs without
ischemic injury
28.
29. The following details must be
observed for surgical planning
1. Nephrometry score, especially the location of the mass and its
proximity to the hilar vessels.
2. Vascular anatomy such as the presence of multiple renal arteries
and veins, early renal arterial bifurcations, and variants of the renal
hilar vasculature.
3. Amount of perinephric fat and the presence (or absence) of
perinephric stranding.
4. Presence (or absence) of other renal masses in both the ipsilateral
and contralateral kidneys.
5. Proximity of the ureter to the renal tumors, especially for lower pole
masses.
6. Renal anomalies such as pelvic kidneys and horseshoe kidneys.
30. Noncontrast CT image detecting
macroscopic fat indicative of
angiomyolipoma
Contrast-enhanced study (magnetic
resonance imaging, CT, or renal
perfusion/ excretion scan) indicating
bilateral renal function.
“Renal protocol” CT imaging, consists of
3 imaging sequences including
precontrast, corticomedullary phase,
and late nephrogenic excretory phase
but cannot determine if the mass is
benign or malignant.
• Ultrasound can fully characterize
cystic lesions and serves as an
effective template for intraoperative
ultrasound which can be highly
effective in locating small subcortical
renal tumors
31. What does these score depict?
These score depict the level of difficulty and eventual success in doing 80 of partial
Nephrectomy esp. By Lap/Robotic.
These score hardly matters for open Sx but still are applicable to open Surgeries also.
32. INDICATIONS FOR SURGERY
• Situations in which radical nephrectomy would render
the patient anephric, with subsequent immediate need
for dialysis
• Unilateral RCC and a functioning opposite kidney when
the opposite kidney is affected by a condition that
might threaten its future function, such as calculus
disease, chronic pyelonephritis, renal artery stenosis,
ureteral reflux, or systemic diseases (e.g., diabetes and
nephrosclerosis)
33. • Indications: for partial Nx
Any T1 (0- 7 cm) even with normal functioning contralateral
kidney.
A tumor in a solitary kidney,
Bilateral kidney tumors
If Contralateral kidney is threatened / affected by stone / CKD
/ HTN
WILMS TUMOUR.
• Contra indications
Nodal mets positive
IVC thrombus / Renal vein thrombus positive
PC system involvement
Renal hilar involvement
34. Timing of surgery in bilateral RCC
• After 1 month, second partial nephrectomy or a
radical nephrectomy on the opposite kidney
• In bilateral, small, synchronous RCCs, bilateral
simultaneous partial nephrectomies are also
performed.
36. LNSS POSITION
• MODIFIED LATERAL DECUBITUS POSITION
• IPSILATERAL CHEST AND SHOULDER ARE
PLACED 30- TO 45-DEGREES OFF THE TABLE.
• OPEN-ENDED 5-FR CATHETER IS PASSED
CYSTOSCOPICALLY UP THE IPSILATERAL
URETER.
• INJECTING METHYLENE BLUE ONCE THE
COLLECTING SYSTEM IS TRANSECTED CAN AID
IN CLOSURE.
37. Anaesthesia : G/A
Deploy : RetroGrade Catheter + Foleys
Position : Lateral flank position
Approach : Extra-pleural, extra-peritoneal flank
Incision : 11th Rib tip incision
Procedure:
• Open the retroperitoneal space
• Loop the ureter : Deploy self retaining retractor
• Dissect the hilum
• Loop the artery and vein
• Start mannitol (20% in 100ml) so 300 ml - 60 mg
38. • Remove the perinephric fat around the normal parts
of kidney. Don’t remove the perinephric fat over
tumour
• Clamp the artery with bull dog clamp
• Cut a hole a plastic sheath and place kidney into it
• Put ice slush all around for 15 min
• Time up – displace the ice
• Mark the tumor and excise with caultry
• Visible open blood vessels are sutured with figure of
8 sutures
• Send for frozen section – NO NEED
• Push 10ml methylene blue 1:1 diluted through RGC
• If any calyceal system opening is seen – close it
• Frozen section negative (if sent for frozen )
• Close kidney over afterHemostasis achieved
• Kidney fixed to posterior musculature to avoid
flipping
• Release clamp
41. POLAR SEGMENTAL NEPHRECTOMY
• Indicated in tumor confined to the upper or lower
pole of the kidney
• Performed by isolation and ligation of the
segmental apical or basilar arterial branch
• The apical artery is dissected, ligated, and divided
• An ischemic line of demarcation appears on the
surface of the kidney and outlines the segment to
be excised
• METHYLENE BLUE CAN BE DIRECTLY INJECTED DISTALLY INTO
THE LIGATED APICAL ARTERY TO BETTER OUTLINE THE LIMITS
42. POLAR NEPHRECTOMY
The kidney is mobilized within Gerota's
fascia while the perirenal fat around the
tumor is left intact
The parenchyma around the tumor is
divided with a combination of sharp and
blunt dissection
After excision of the tumor, the
remaining transected blood vessels on
the renal surface are secured with
figure-of-eight 4-0 chromic sutures
43. WEDGE RESECTION
• Indicated in peripheral tumors on the surface of
the kidney, particularly ones that are larger or
not confined to either renal pole
• This technique is associated with heavier
bleeding
• It should be done with temporary renal arterial
occlusion and surface hypothermia.
• In a wedge resection, the tumor is removed with
margin of normal renal parenchyma
44. Wedge resection for a peripheral tumor
RENAL DEFECT CLOSED BY TWO WAYS.
CLOSED ON ITSELF BY APPROXIMATING THE
TRANSECTED CORTICAL MARGINS WITH SIMPLE
INTERRUPTED 3-0 CHROMIC SUTURES AFTER
PLACEMENT OF A SMALL PIECE OF OXYCEL AT
THE BASE OF THE DEFECT.
PERIRENAL FAT MAY SIMPLY BE INSERTED INTO
THE BASE OF THE RENAL DEFECT AND SUTURED
TO THE PARENCHYMAL MARGINS WITH
INTERRUPTED 4-0 CHROMIC SUTURES
45. TRANSVERSE RESECTION
• It is done to remove large tumors that involve
the upper or lower portion of the kidney
• Major branches of the renal artery and vein
supplying the tumor-bearing portion of the
kidney are identified in the renal hilum, ligated,
and divided
47. PARTIAL NEPHRECTOMY FOR CENTRAL TUMORS
• For patients with central tumors, complete delineation of the
renal arterial and venous supply is mandatory for surgical
planning.this information can be obtained with three-
dimensional CT scanning
• It is performed after temporary occlusion of the renal artery and
vein
• The tumor is mobilized and isolated as much as possible by
dissecting away adjacent segmental renal vessels
• The main renal vein is mobilized and retracted in either direction
to expose a central tumor by ligation and division of small
adjacent or overlying venous branches
48. Mobilization of the left renal vein to exposure
tumor in the renal hilum by ligation and
division of small renal venous branches.
49. SIMPLE ENUCLEATION
• SURROUNDED BY A DISTINCT PSEUDOCAPSULE OF
FIBROUS TISSUE ( VERMOOTEN, 1950.
• CIRCUMFERENTIAL INCISION OF THE RENAL
PARENCHYMA AROUND THE TUMOR AT ANY
LOCATION, OFTEN WITH NO VASCULAR OCCLUSION.
• HIGHER RISK OF LEAVING RESIDUAL MALIGNANT CELLS
IN THE KIDNEY.
• Enucleation is indicated only in von Hippel–Lindau
disease and multiple low-stage encapsulated tumors
involving both kidneys
50. EXTRACORPOREAL PARTIAL NEPHRECTOMY AND
AUTOTRANSPLANTATION
• It was described by Calne 1973, Gittes and McCullough
1975
• Indicated in large complex tumors involving the renal
hilum
ADVANTAGES
• Optimum exposure
• Bloodless surgical field
• Maximum conservation of renal parenchyma
• Greater protection of the kidney from prolonged
ischemia
51. DISADVANTAGES
• longer operative time need for vascular and ureteral
anastomoses
• increased risk of temporary and permanent renal failure
PROCEDURE
• It is performed through a single midline incision
• The kidney is mobilized and removed outside Gerota's
fascia with ligation and division of the renal artery and
vein
• The removed kidney is flushed with 500 mL of a chilled
intracellular electrolyte solution and submerged in ice-
slush saline solution to maintain hypothermia
52. A, The kidney is removed outside Gerota's fascia.
B, The tumor is excised extracorporeally
C, Pulsatile perfusion or reflushing is used to identify transected blood vessels
D, The kidney is closed on itself
53. • After the tumor has been completely resected, the
renal remnant may be reflushed or placed on the
pulsatile perfusion unit to facilitate identification and
suture ligation of remaining bleeding points
• The defect is closed by suturing the kidney on itself
• Autotransplantation into the iliac fossa is done by the
same vascular technique as for renal
allotransplantation.
• Urinary continuity may be restored with
ureteroneocystostomy or pyeloureterostomy with
internal ureteral stent
• Drain is positioned extraperitoneally in the iliac fossa
54. HAEMOSTASIS & COLLECTING SYSTEM
CLOSURE
• AFTER EXCISION OF THE TUMOR,
THE REMAINING TRANSECTED
BLOOD VESSELS ON THE RENAL
SURFACE ARE SECURED WITH
FIGURE-OF-EIGHT 4-0 CHROMIC
SUTURES.
• RESIDUAL COLLECTING SYSTEM
DEFECTS ARE SIMILARLY CLOSED.
• WITH THE RENAL ARTERY STILL
CLAMPED BUT WITH THE RENAL
VEIN OPEN, HYPERINFLATE THE
LUNGS AND THEREBY RAISE THE
CENTRAL AND RENAL VENOUS
PRESSURES.
58. CRYOSURGERY
• RAPID FREEZING, GRADUAL THAWING, REPETITION OF THE
FREEZE-THAW CYCLE.
• IMMEDIATE CELLULAR DAMAGE AND DELAYED MICROCIRCULATORY
FAILURE .
• ICE FORMATION IN THE EXTRACELLULAR SPACE-HYPEROSMOTIC
WATER PERMEATES FROM THE IC COMPARTMENT.
• LEADING TO INTRACELLULAR SOLUTE CONCENTRATION AND
DEHYDRATION, WHICH CAUSE DESICCATION TRAUMA. CONTINUED
RAPID SUPERCOOLING LEADS TO CELLULAR DAMAGE—
INTRACELLULAR ICE FORMATION.
• DELAYED MICROCIRCULATORY FAILURE OCCURS DURING THE SLOW
THAW PHASE OF THE FREEZE-THAW CYCLE, LEADING TO
CIRCULATION ARREST AND CELLULAR ANOXIA
59.
60. RADIOFREQUENCY ABLATION
• HEAT ABOVE 45°C LEADS TO IRREVERSIBLE CELLULAR
DAMAGE, AND TEMPERATURES HIGHER THAN 55°C TO
60°C RESULT IN IMMEDIATE CELL DEATH.
• RADIOFREQUENCY ABLATION INDUCES EXCITATION OF
IONS, FRICTIONAL FORCES, AND HEAT.
• TEMPERATURES IN EXCESS OF 100°C ARE OBTAINED.
• DISADVANTAGE IS THAT THE TREATMENT EFFECT IS
MORE DIFFICULT TO MONITOR IN REAL TIME—THERE
IS NO TRUE “ICE BALL” .
• PREDICTABLE TARGET ZONE OF UP TO 4.0 CM TO BE
TREATED IN MOST CASES.
61.
62. Thermo ablation
• Advanced age .
• Significant comorbities.
• Local recurrence after
previous NSS.
• Multifocal tumors
CRYOABLATION & RFA
HIFU & CYBERKNIFE
Active survelliance
• Small.
• Well marginated .
• Homogeneous .
• Non-cancer causes of death
& the risk of intervention
Vs
Risk of RCC progression(0.28
cm/yr).
• Serial renal imaging at 6 to
12-month intervals.
