Introduction
Renal cell carcinoma (cancer of the kidney) in a single kidney presents a unique clinical challenge to surgeons. Partial nephrectomy (a surgical procedure to remove kidney parts partially) has good oncological and renal functional outcomes with an acceptable complication rate. Renal function can be preserved by partial nephrectomy in a solitary kidney. The patient who underwent partial nephrectomy for a tumor in a solitary kidney had excellent cancer-specific survival and retained sufficient renal function to avoid permanent hemodialysis. The treatment of patients with renal cancer syndrome and multiple tumors is complicated due to the persistent nature of the disease, especially in those with only one kidney remaining. Even when these patients are treated, they are still at risk for tumor formation or recurrence in the remaining renal unit. As many as 85 % of patients with tumor recurrence at 10 years are seen. Such patients are likely to require multiple surgical interventions. While ablative therapy may be useful in select patients with local recurrence, in others repeat partial nephrectomy remains the most appropriate treatment.
What Is Repeat Partial Nephrectomy on the Solitary Kidney?
Repeat partial nephrectomy (RPN) on a solitary kidney is a complex surgical procedure that involves removing a portion of the kidney that was previously operated on. Surgery on a previously operated kidney can be difficult as well as technically demanding. The procedure is typically performed on patients with kidney tumors or other conditions that require the removal of a portion of the kidney. This article will explore the various aspects of repeat partial nephrectomy on the solitary kidney, including patient selection, surgical technique, and outcomes.
How Patients Are Selected for Repeat Partial Nephrectomy?
Patient selection for repeat partial nephrectomy on the solitary kidney is critical to the success of the procedure. Patients with a history of previous kidney surgery and those with a solitary kidney require careful evaluation before undergoing a repeat procedure. The evaluation includes a thorough review of the patient's medical history, physical examination, and diagnostic tests such as computed tomography (CT) or magnetic resonance imaging (MRI) scans. The following are the ways by which patients are selected for surgery:
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Preoperative Assessment - The analysis which is made before surgery is known as preoperative assessment. It includes physical examination, routine laboratory studies, and abdominal computerized tomography or magnetic resonance imaging.
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Clinical Characteristic - Baseline clinical characteristics such as age, gender, height, and weight were recorded in each patient along with steroid requirement and previous abdominal surgeries. Patients who are good candidates for RPN include those with small tumor size, good kidney function, and a healthy contralateral kidney.
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Operative Data - Patients who have undergone previous partial nephrectomies may also be candidates for RPN if the remaining kidney function is adequate and the tumor has not recurred. Operative data include the need for renal hilar clamping (clamping any previously damaged renal parts), renal bleeding time, procedure duration (start of anesthesia to transfer to the postoperative anesthesia or intensive care unit), and disease burden (number of renal lesions, lesion size, and pathological grade).
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Transfusion Requirement - Blood transfusion may be required if visceral or vascular injury occurs.
How Is Repeat Partial Nephrectomy Performed?
The surgical technique for RPN on the solitary kidney is similar to that used for a primary partial nephrectomy. The procedure is typically performed using minimally invasive techniques, such as laparoscopy or robot-assisted surgery, to minimize the risk of complications. The surgery is performed after preoperative assessment in the following ways:
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Anesthesia - The patient has been given anesthesia so that they can not feel any pain during surgery.
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Incision - An incision was made at the 11th rib to reach the kidney. The renal artery and vein were then block-clamped at the renal hilum.
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Suture - The opened artery and vein were ligated using non-absorbable sutures. The opened collecting system was repaired using absorbable sutures.
What Are the Outcomes for Repeat Partial Nephrectomy in Patients?
The outcomes of RPN on the solitary kidney are generally good, with a low risk of complications and a high rate of kidney function preservation. Studies have shown that patients who undergo RPN on the solitary kidney experience similar outcomes to those who undergo primary partial nephrectomy. The outcomes of the surgery are measured in the following ways:
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Postoperative outcome was measured by the need for blood transfusion, and prolonged urinary leakage (defined as the need for a drain at discharge home).
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The outcomes are analyzed based on renal unit loss, the need for subsequent reoperation, cardiovascular events, and the need for acute or chronic hemodialysis (artificial kidney).
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The kidney function is analyzed by postoperative serum creatinine and glomerular filtration rate (GFR) in all patients. Postoperative GFR was determined at least four weeks and then 12 months after surgery.
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Imaging studies are used for analyzing outcomes after surgery. Patients were followed initially one or three months after surgery and every six to 12 months thereafter with abdominal and chest imaging.
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The oncological outcomes were assessed by evaluating the presence of locally advanced disease on imaging and the need for reoperation for recurrent or solid renal lesions.
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One study published in the Journal of Urology found that RPN on the solitary kidney resulted in excellent cancer control and preservation of renal function in patients with recurrent tumors. The study also found that the overall complication rate was low, with only six percent of patients experiencing major complications.
What Are the Complications of Repeat Partial Nephrectomy?
No complications such as other organ injuries and loss of remnant kidney were reported in the repeat partial nephrectomy. Postoperative complications can occur in the patients of the repeat partial nephrectomy group such as acute kidney injury and prolonged urine leaks. The patient with acute kidney injury received conservative management, which led to spontaneous resolution. No patient experienced the loss of the remnant kidney or death during the perioperative period.
Conclusion
Repeat partial nephrectomy on the solitary kidney is a complex surgical procedure that requires careful patient selection, surgical technique, and postoperative management. However, with careful evaluation and skilled surgical technique, the procedure can result in excellent outcomes, including cancer control and preservation of kidney function. Patients with a history of previous partial nephrectomies or those with a solitary kidney should discuss the option of RPN with their healthcare provider to determine if the procedure is appropriate for their individual situation.
