Laparoscopic Partial Nephrectomy - Novel Use of the VLOC suture to Reduce Warm Ischemia- PART 1

The gold standard treatment of small renal masses (4cm or less) is a partial nephrectomy. This means that only the tumor is removed while preserving the majority of the remaining kidney. While we generally only require a portion of 1 kidney, there is growing proof that preserving as much kidney tissue has significant health benefits. As such, the patient and urologist should always optimize treatment to maximize global kidney function.

With further growth and experience with laparoscopy, minimally invasive techniques for partial neprhectomy exist, which include laparoscopic partial nephrectomy (LPN) and thermal needle ablation. LPN has a demonstrated track record of offering excellent cancer care while minimizing blood loss, hospital stay and complications in experienced surgeons' hands. Once of the disadvantages of the LPN is the fact that the tumor excision and the kidney defect repair (renorrhaphy) must be done within 20- 30 minutes maximum to avoid ischemic related kidney injury. When LPN is performed, the blood supply to the kidney is temporarily clamped to prevent blood loss. During that time, the kidney remains at body temperature (38C) and cell metabolism continues at its normal rate. As such, the experienced surgeon must move quickly and efficiently. In the event that longer times are requied, an open approach should be employed to place ice around the kidney and cool it to 14-18C and slow down its metabolism. This cold ischemia affords the surgeon up to 2 hours to excise the tumor and repair the defect.

In our practice, we has incorporated the VLOC self-retaining suture in our surgical technique for deep layer kidney defect closure. The VLOC has a novel unidirectional barb system that helps maintain its place in tissue (does not slide back and lose tension). There is an end loop and this removes the need for knot tying. Bottom line- faster and more efficient suturing. The following video demontrates our novel self anchoring of 1 or 2 VLOCs in strategic locations to facilitate tumore excision and improve the suture repair, thus minimizing warm ischemia time (WIT). We have been able to reduce WIT by 4-5 minutes particularly in challenging upper pole, larger, lateral and posterior tumors where instrument triangulation is difficult.

Video by Dr. Kevin C. Zorn.