Renal cell carcinoma(RCC) is one of the most common urologic neoplasms, The incidence of male was up to > 15/100 000 in several Northern and Eastern European countries and among US blacks [22]. Although the stabilization of mortality trends has been achieved in many highly developed countries, RCC identification continues to increase worldwide, along with the popularization of imagining techniques such as ultrasound and CT scans [22, 23]. A considerable part of these tumors are primary, small and discovered incidentally, which require surgical intervention when conservative treatment fails.
The 2009 version of the American Urological Association guidelines recommends that nephron-sparing approaches, such as partial nephrectomy are appropriate for clinical stage one (< 7 cm) renal masses [1]. LPN is becoming increasingly standardized due to the feasibility and efficacy of laparoscopic techniques. Moreover, LPN has numerous advantages, which is better than open partial nephrectomy ,terms of blood loss, WIT, operative duration, perioperative morbidity and hospitalization. However, three shortcomings and technical difficulties of LPN have prevented it from widespread use and application. Firstly, intracorporeal suturing for hemostasis, renal parenchymal repair and closure of the pelvicalyceal, especially in the retroperitoneal route due to the relatively small space available for operation,all those performed were complicated. Therefore, technological improvement is needed to flatten the steep learning curve specific to the laparoscopic approach. Secondly, intracorporeal suturing cause WIT been longer than before. Every minute of WIT counts when the renal hilum is clamped, Hence, every additional minute is associated with a 5% increase in the risk of developing acute renal failure, and 6% increase in the risk of new-onset stage IV chronic kidney disease during the follow-up [24].Hence, it is important to improve the suturing process and reduce the WIT. Thirdly, LPN has been associated with an increased rate of bleeding and urinary leak [25]. Suturing is the most effective method of hemostasis and preventing urinary leaks [4]. SRBDS is an advanced surgical suturing to reduce those complications.
SRBDS consists of delayed-absorbable suture material and 2 needles for different direction suture, it is a relative new method in the field of surgical suturing. There are several advantages for SRBDS. Firstly, SRBDS has barbs lining at intervals of 1.25 mm, which could prevented slippage through “self-cinching mechanism” [4] and could free one hand from maintaining the wire tension. Therefore, SRBDS provides a feasible surgical method to decrease the learning curve of complex laparoscopic tasks, especially intracorporeal suturing. Secondly, SRBDS has two needles and can be used for suture in different directions, from the suture midpoint. In addition, SRBDS does not require the use of knotting or clips, such as Hem-o-lok and Lapra-Ty clips. At the end of the suturing process, the suture could be cut off directly. SRBDS is a method which carried out separately in the inner and outer layer by running suture, which make the suture easier and more efficient. Finally, SRBDS results in less parenchymal tearing and avoids the “cheese-slicing” because of this suture process with balanced force. which could reduce complications such as bleeding and urinary leakage [4].
In China, Wang and Wahafu have confirmed the effectiveness and safety of SRBDS in LPN [4, 6]. In their studies, bi-directional barbed suture was used in the retroperitoneal route of LPN, and the left quill line was used to tie a knot, or a Hem-o-lock was used to close the end of the suture. In addition, Xu Zhang performed the running suture after anchoring with one Hem-o-lok clip (Weck surgical instruments) at one end, and set another anchor at the other end after suturing [4]. These approaches are quite different from our SRBDS method. For us, the transperitoneal approach is more favorable because of its larger operative space, wider separation of ports, and more familiar landmarks. Therefore, all surgical interventions were finished in the transperitoneal route of LPN, regardless of tumor location. Consequently, the purpose of this article was to prove that the SRBDS is an alternative method for suturing without using any knot or clip in the transperitoneal LPN.
Time and WIT was reduced if you comparing to the previous studies [4, 6]. We removed the bulldog clamp before suturing the outer layer. because early withdrawal of the bulldog clap might reduced the WIT in the future. If we compare to traditional methods ,We did not use any hemostatic agents or glues, hem-o-lock clips, LARPA-TY clips or knots through the process, and directly cut off the quill line at the end of the suture. Hence, according to our summaries, SRBDS provides an efficient and feasible choice for T1 renal neoplasms.
In our opinion, safety always are important. SRBDS slightly decreased the mean hemoglobin (estimated blood loss 67 ml), which was similar to the results obtained by Wang (60.5 ml), but higher than the volume reported by Wahafu (43.44 ml) (Table 3). We deduced that tumor size may be responsible for these differences. The increase in tumor size is associated with longer operative time and blood lost. Meanwhile, the blood loss is estimated during surgery, and is associated to the surgeon’s experience and intraoperative irrigation. Consider of the lack of clips and lower suture cost into account, SRBDS is a feasible nephrorrhaphy choice in LPN.
According to our outcome, that reveals the complications were rare and usually could be control. Actually,there were few disadvantages in our study. Follow-up was short (12 months) and the number of participants was small. The trial also lacked randomized control. In addition, glomerular filtration rate evaluated by nuclear medicine was not carried out, due to the restrictions of health care cost during the follow-up, so we failed to assess the impact of surgery on the operated kidney. These shortcomings will be addressed in a subsequent study.
Anyway, SRBDS is a method which could provide favorable outcomes with lower morbidity and complications over a one-year follow-up period.