Abstract and Introduction
Abstract
Background and Objective: Nephron sparing surgery (NSS) is the preferred management for clinical stage T1 (cT1) renal masses. In recent years, indications have expanded to larger and more complex renal tumors. In an effort to provide optimal patient outcomes, urologists strive to achieve the pentafecta when performing partial nephrectomy. This has led to the continuous technologic advancement and technique refinement including the use of augmented reality, ultrasound techniques, changes in surgical approach and reconstruction, uses of novel fluorescence marker guided imaging, and implementation of early recovery after surgery (ERAS) protocols. The aim of this narrative review is to provide an overview of the recent advances in pre-, intra-, and post-operative management and approaches to managing patients with renal masses undergoing NSS.
Methods: We performed a non-systematic literature search of PubMed and MEDLINE for the most relevant articles pertaining to the outlined topics from 2010 to 2022 without limitation on study design. We included only full-text English articles published in peer-reviewed journals.
Key Content and Findings: Partial nephrectomy is currently prioritized for cT1a renal masses; however, indications have been expanding due to a greater understanding of anatomy and technologic advances. Recent studies have demonstrated that improvements in imaging techniques utilizing cross-sectional imaging with three-dimensional (3D) reconstruction, use of color doppler intraoperative ultrasound, and newer studies emerging using contrast enhanced ultrasound play important roles in certain subsets of patients. While indocyanine green administration is commonly used, novel fluorescence-guided imaging including folate receptor-targeting fluorescence molecules are being investigated to better delineate tumor-parenchyma margins. Augmented reality has a developing role in patient and surgical trainee education. While pre-and intra-operative imaging have shown to be promising, near infrared guided segmental and sub-segmental vessel clamping has yet to show significant benefit in patient outcomes. Studies regarding reconstructive techniques and replacement of reconstruction with sealing agents have a promising future. Finally, ERAS protocols have allowed earlier discharge of patients without increasing complications while improving cost burden.
Conclusions: Advances in NSS have ranged from pre-operative imaging techniques to ERAS protocols Further prospective investigations are required to determine the impact of novel imaging, in-vivo fluorescence biomarker use, and reconstructive techniques on achieving the pentafecta of NSS.
Introduction
In 2020, renal malignancies compromised 2.4% of cancer diagnoses with an incidence of over 431,000 cases, worldwide.[1] The prevalence is highest in the United States and Western Europe; however, the incidence is projected to rise in Asia, Africa and Latin America as these countries continue to transition to a Western lifestyle. The management of renal masses has continued to evolve over time. Open partial nephrectomy (PN) was first performed in 1887 but since the advent of minimally invasive surgery in urology, this approach has been favored for many renal tumors.[2,3] The first laparoscopic partial nephrectomy (LPN) was performed in 1990 with the robot-assisted approach following approximately a decade later.[4–6] Currently, AUA guidelines recommend PN for cT1a tumors; however, with advances in the understanding of vascular anatomy and development of advanced techniques, PN has been performed on complex, unfavorably located, larger tumors, and in solitary kidneys.[7–16]
The principles of robotic-assisted partial nephrectomy (RPN) have also changed over time. Initially, the concept of the "trifecta" was used to evaluate the success of RPN. However, as surgeons have progressively performed more complex RPN, an understanding of the functional ramifications of surgery have become better delineated. This ultimately resulted in the expansion of the trifecta to the so-called "pentafecta".[17] In order to achieve the RPN pentafecta while removing larger and more complex renal masses, a more detailed understanding of renal anatomy and its vasculature has been investigated. Through concepts such as selective vascular clamping, three-dimensional (3D) modeling, and intraoperative imaging techniques, great strides have been made in the oncologic outcomes and preservation of renal function in those with renal masses. In this narrative review, we discuss the many recent technological advances that have been implemented in the ever-changing landscape of RPN. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-23-107/rc).
Transl Androl Urol. 2023;12(7):1184-1198. © 2023 AME Publishing Company
