COMPARISON OF RUNNING “SLIDING CLIPS” SUTURE VERSUS SEPARATED STITCHES RENORRAPHY DURING OPEN LOMBOTOMIC PARTIAL NEPHRECTOMY
Renal cell carcinoma (RCC) accounts for approximately 2–3% of all adult malignancies. More than 50% of all RCCs diagnosed are a localised stage (ie, T1–T2N0M0 or stage I–II). Nephron-sparing surgery (NSS; partial nephrectomy) has been the accepted mode of treatment when radical nephrectomy would render the patient anephric or at high risk for subsequent renal replacement therapy. This surgical procedure can be performed either by open, classic laparoscopic or robotic assisted approach. Independently by the access, there is still a lack of consensus about the best method to execute renorrhaphy, the most crucial part of this intervention [1-2]. Objective of the present study was to compare two different renorrhaphy techniques during open lombotomic partial nephrectomy. To our knoweledge, this is the first study investigating this very important topic.
Methods and results
All patients coming to our centre candidates to conservative renal surgery were recruited in this prospective study. Subjects were actively randomized in two homogeneous and equal groups according to body mass index (BMI) and R.E.N.A.L. nephrometry score (min 3 – max 12). In all cases it was performed an open flank approach with an incision practiced trough the bed of 11th rib. The renal artery and vein were controlled by Satinsky clamps prior of tumor excision. The Gerota fascia and the perirenal fat were incised as necessary to get a perfect vision of the renal mass and to allow good handling for tumour excision and suturing. A margin of 5 mm of macroscopic healthy tissue was resected in all cases in order to avoid positive margins. In both groups the interstitial tissue (medulla) and collecting system were closed using a running 3-0 Vicryl® suture. After tumor removal we performed two different techniques of renorraphy. In group one separated CT-X needles Vicryl® 0 sutures were placed on both sides of renal wound. A different numbers of sutures were placed according to the size of the renal defect. Afterwards the two free ends of the suture were tied together above a bolster of Tabotamb® to enforce the pressure on the resection area and to avoid tearing out the sutures. In group two it was performed a “sliding clips” renorraphy technique: a knot was tied at the end of a 0 PDS® suture. Above the knot, it was placed an Hem-o-Lock®. A running suture were then performed placing at each passage of the needle at both side of the renal wound an Hem-o-Lock®. To tighten, the loose end of each suture was grasped with a needle driver and tension was applied perpendicular to the capsule in order to minimize the risk of tearing. In both groups it was applied at the end of the renorraphy a Flowseal® solution on the renal wound to ensure haemostasis. All surgeries were performed by the same experienced surgeon (SP). The outcome measurement was the comparison in both groups of X2 distribution of the following outcomes: warm ischaemic time, existimated blood loss, hospital stay and drainage leakage.
40 patients entered the study and were assigned equally to the two groups. Results were the following respectively for group one (separated stitches) and group two (sliding clips). Renal score: 5,85 ± 1,46 ; 5,9 ± 1,48 (p 0,73). BMI: 27,8 ± 4,7 ; 28,15 ± 4,4 (p:1). Warm ischaemic time (minutes):18,45 ± 2,72 ; 23,75 ± 1,77 (p 0,027). Existimated blood loss (ml): 158,2 ± 61,5 : 170,75 ± 65 (p 0,002). Hospital stay (days): 6,9 ± 1,2 ; 6,1 ± 0,9 (p 0,99). Drainage leakage (ml): 167 ± 46,8 ; 139,5 ± 48.4 (p 0,001)
All patients were safely discharged without major complications. One patient of each group required blood transfusions.
Patient and tumour characteristics permitting, the current oncological outcomes evidence base suggests that localised RCCs are best managed by NSS rather than by radical nephrectomy irrespective of surgical approach. Where open surgery is deemed necessary, open NSS oncological outcomes are at least as good as open radical nephrectomy and should be the preferred option when technically feasible. In this study we found that sliding clips renorraphy provided a lower leakage trough the drainage than separated stitches suture but increased blood loss and required an higher ischaemic time. No differences were found at hospital stay between the two groups. We are currently leading the same study at our Institution using a Robotic assisted laparoscopic approach.
1) MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, Hilvano-Cabungcal AM, Royle P, Stewart F, MacLennan G, MacLennan SJ, Dahm P, Canfield SE, McClinton S, Griffiths TR, Ljungberg B, N'Dow J. UCAN Systematic Review Reference Group; EAU Renal Cancer Guideline Panel. Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol. 2012 Dec;62(6):1097-117.
2) MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, Hilvano-Cabungcal AM, Royle P, Stewart F, MacLennan G, MacLennan SJ, Canfield SE, McClinton S, Griffiths TR, Ljungberg B, N'Dow J. UCAN Systematic Review Reference Group; EAU Renal Cancer Guideline Panel. Systematic review of oncological outcomes following surgical management of localised renal cancer. Eur Urol. 2012 May;61(5):972-93.