Role of Microsurgery in Organ-Preserving Surgeries in Uro-oncology

Abstract

Organ preservation surgery is the need of the hour in cancer management whenever it is feasible. Vascular continuity is a must for organ preservation. We found such same in this article. We retrospectively collected the data of all cases which operated for either salvage of organs such as kidney or iatrogenic injury to renal pedicle or any kind of salvage procedure done in uro-oncological cases from June 2022 to January 2023 in our hospital. Data were analysed and presented using descriptive analysis. In a total of five such cases, two required end-to-end primary repair of the renal artery and vein, and one required vein graft for renal artery. In one case, we had to flip the inferior mesenteric artery to anastomose it to the renal artery. One case of renal autotransplant was done. All cases have good outcomes in the form of renal function and oncological safety. Although a lot of urologists are trained in renal transplants and arteriovenous fistula formations, the results can further be improved with good microvascular surgeons in the team in uro-oncology settings too.

Introduction

Microvascular repair plays a vital role in managing severe abdominal trauma by offering a chance for tissue and organ salvage, functional recovery, and improved patient outcomes [1]. Abdominal organs salvage in advanced malignancies is also one important untouched area where this expertise can open new horizons.

With the increasing incidence of renal and retroperitoneal malignancies, approaches to renal cancers are changing towards more and more organ-preserving surgeries too. Despite increasing trends towards the use of nephron-sparing surgery, radical nephrectomy remains one of the most common management approaches for kidney cancer. In these cases, a single remaining functioning kidney is precious. Functioning kidney preservation condition has a major impact on the quality of life of the patient and is desirable for better clinical and functional outcomes. Early identification of vascular arterial and/or venous injury and prompt intervention using microvascular anastomotic techniques can restore or improve vascularity for viscera salvage uneventful healing of tissues and avoid reduced complications [2].

Resection surgeons routinely employ preservation strategies for vital organ vascularity. Collaboration between resecting onco-surgeon and micro-vascular surgeon can further help in increasing the scope of organ and viscera preservation in radical resections, unintended injuries, or variable anatomical situations.

Material and Methods

A retrospective analysis was done of consecutive cases operated in our centre for microvascular salvage of the kidney during cancer resection and restoration/reconstruction surgery. The study period was from June 2022 to January 2023 for microvascular salvage of the kidney during cancer resection and reconstruction surgery was done. Data were collected from hospital electronic media records and the departmental database. The aim is to assess the feasibility of microvascular surgical salvage of kidneys in emergencies. Salvage was attempted irrespective of the ischemia time due to the vital organs involved.

In all these cases, we salvaged the viscera by restoring arterial and venous continuity using microvascular anastomotic techniques. The microvascular technique implies some standard plastic surgery practices; use of a microscope preferably in our series, for dissection and vascular suturing; use of microvascular instruments and fine suture materials like 9-0 polyamide, meticulous suturing of vessels with pinpoint accuracy and complete avoidance of adventitial exposure to intima. Vein grafts were used when required. Intraoperative Doppler was done to confirm vascular continuity. Postoperatively, the patient was monitored for urine output, biochemical investigations, and Doppler and dynamic scans to assess renal function.

Surgical Technique and Decision-Making Process

Scenario 1: Inferior Mesenteric Artery Transposition

In a 15-year-old male patient, a known case of Gilbert syndrome underwent choledochal cyst excision and hepaticojejunostomy at the age of 12 years and was admitted for acute abdominal pain and found to have left renal mass completely replacing whole renal parenchyma. During the resection of the tumour, while removing the right para-aortic lymph nodes, the right renal artery sustained a thermal injury (by harmonic) at its origin. A segment of around 2 cm was not usable because of thermal injury. The end-to-side anastomosis was not possible without a graft. The decision was taken to flip the inferior mesenteric artery (IMA) as a donor vessel. IMA was dissected till rectal branches and 9-cm pedicle length were dissected and flipped (Fig. 1). End-to-end anastomosis was done using a 9–0 polyamide suture under a microscope (Fig. 2). Intraoperative renal Doppler confirmed good blood flow in the whole kidney (Fig. 3). During the postoperative period, the patient went into acute kidney disease, and dialysis was required. After multiple settings of dialysis, kidney function recovered completely. A post-operative DTPA (Diethylenetriamine pentaacetate) scan showed a right kidney GFR (Glomerular filtration rate) of 68 ml/min patient completed 14 cycles of chemotherapy. Post-chemotherapy renal function tests are normal, and urine output is adequate.

Fig. 1.

Dissected IMA

Fig. 2.

Inferior mesenteric artery anastomosis with renal artery

Fig. 3.

Well perfused kidney after anastomosis

Scenario 2

A 35-year-old female patient case of Ewing’s sarcoma was posted for retroperitoneal Ewing’s sarcoma resection with right nephrectomy and cholecystectomy. The left renal artery was injured during dissection. Left renal artery reconstruction was done with a saphenous vein graft (6 cm); anastomosis proximal to the right renal artery stump and distal-left renal artery was done using 8–0 polyamide suture. Intraoperative Doppler showed good inflow to the kidney. This patient also did well in the postoperative period and completed his recovery uneventfully.

Scenario 3

In a 22-year-old male patient, a known case of left testicular non-seminomatous germ cell tumour underwent high inguinal orchidectomy for the same and presented with a left peritoneal mass. On evaluation, the mass was found to be encasing the left renal vascular pedicle and having elevated serum markers for germ cell tumours. He underwent chemotherapy and was planned for retroperitoneal lymph node dissection with left nephrectomy. Intraoperatively, the reconstructive team was called in to assess the possibility of salvaging the kidney, and the decision was taken to perform a renal autotransplant at the same place after sacrificing the involved segment of the renal vascular pedicle. The kidney was dissected out of tumour mass with around 1 cm of pedicle length for both artery and vein (Fig. 4). The renal artery was repaired at hilum ex vivo on the table using 9–0 polyamide suture (Fig. 5). The kidney was perfused with the cooling and preservative solution to decrease the cold schema time during the whole time (Fig. 6). The renal vascular pedicle was anastomosed to the remnant native vascular pedicle using 7–0 polypropylene suture. Intraoperative Doppler showed patent anastomosis, and the kidney was pink (Fig. 7). Some urine had also started coming out of the ureter immediately after arterial anastomosis which was a good sign. It was followed by uretro-uretric anastomosis with a double J stent by the urology team. Postoperatively, kidney showed good function.

Fig. 4.

Dissected kidney from tumour

Fig. 5.

On table renal artery hilum repair

Fig. 6.

Perfusion of kidney with preservative solution

Fig. 7.

Renal vascular pedicle anastomosis with remnant vascular pedicle

A similar case was done in a 16-year-old female with a benign neuroendocrine tumour in which two renal arteries and one vein were anastomoses in orthotropic renal auto transplant, and the patient is doing well postoperatively.

Scenario 4

In a 40-year-old female patient, with a known case of right renal cell carcinoma, the patient was posted for a right nephrectomy. During resection, the left renal artery was injured. The decision was taken to do end-to-end renal artery repair using 8–0 polyamide suture. Intraoperative renal Doppler confirmed good blood flow in the whole kidney. The postoperative period was uneventful with adequate urine output and normal renal function tests.

Scenario 5

A 32-year-old male patient with a known case of right testicular seminoma was posted for retroperitoneal lymph node dissection. Intraoperatively, there was an injury to the left renal artery which was repaired primarily using 8–0 polyamide suture. Intraoperative Doppler was done, showing normal flow. The postoperative period was uneventful.

Discussion

The extensive resections performed in retroperitoneal space malignancies carry a significant risk of severe morbidity and potential mortality for the patient. Therefore, it is essential to prioritise the preservation of as much healthy tissue as possible while ensuring oncological safety [3]. The occurrence of vascular insufficiency, either arterial or venous, can be attributed to various factors.

The need to resect blood vessels can arise due to direct tumour involvement or the necessity to obtain adequate surgical margins. This decision may be planned, made during the surgery itself, or occur inadvertently. Renal autotransplant is a well-established procedure in non-oncological settings such as chronic pain, but these principles can be very well used for organ-preserving surgeries in uro-oncology too [4]. The schema time can be minimised using cooling and preservative solution which will keep the kidney cold, and damage to it can be minimal.

Accidental damage to blood vessels during surgery can lead to luminal disruption and subsequent vascular insufficiency. These injuries are usually due to lymph node enlargement/badly adherent nodes or fibrotic beds. These injuries are due to some energy source almost always and will need either mobilisation of the kidney to reduce the gap between vascular continuity between the ends of the vessel after freshening up the edges or it will need a vein graft [5]. The use of inferior mesenteric artery flip is also unique as one can get around 8 to 10 cm of length from it and it can be harvested without vascular compromise to the colon as there is an alternative supply distal to middle colic vessels as shown in the Figure [6]. Gonadal vessels can also be used as an alternative to vein grafts if available.

Unexpected anatomical variations in combination with resection can precipitate vascular insufficiency. The urgency of addressing these situations cannot be overstated, as warm ischemia time for the kidney is 1 h and cold ischemia time is 4–6 h. The consequences of failing to reverse ischemia and prevent necrosis in these organs are grave [7].

Microvascular surgery is a crucial approach for reversing vascular insufficiency, either arterial or venous, in renal cancers. The principles of microvascular surgery involve meticulous vessel repair with fine sutures, and end-to-end or end-to-side anastomosis using microsurgical techniques. Bridging the gap in vessel ends can be achieved using autologous vein/arterial grafts, alloplastic tubularized grafts (commonly poly-tetra-flouro-ethylene), or occasionally, a new non-anatomical vessel source [8].

To perform successful microvascular surgery, magnification through a surgical microscope, sutures (such as monofilament polyamide in 8–0, 9–0, or 10–0 sizes), and appropriate microsurgical instruments are essential. The vessels are anastomosed “end-to-end” when their lumens match, and an “end-to-side” configuration is used if lumens do not match or if preserving the donor/recipient vessel is vital [9].

Incorporating a microvascular surgeon into the cancer resecting team and embracing microsurgical tenets can provide substantial benefits. By preserving or reconstructing vital vessels through microdissection, the criterion for R0 resection can be extended, making tumours previously deemed inoperable now feasible for surgery. Routine use of microsurgery can also lower the threshold for vascular resection and reconstruction, and inadvertent injuries can be more predictably addressed. Furthermore, microvascular surgery ensures the perfusion or salvage of reconstructed organs with signs of vascular insufficiency. Close cooperation, communication, and coordination between the resection and microvascular teams are vital for success, and preoperative joint clinics or discussions are highly recommended [10].

The current state of abdominal visceral resection surgery in relation to blood vessels indicates a trend of pushing the boundaries of operability and vascular resection to achieve better patient outcomes. We emphasise the importance of microvascular practices in advanced urological cancers that can be made resectable as vessels can be repaired and re-anastomosed and kidneys can be saved. With precise microvascular techniques, the complication rate can be minimised in such cases. Experienced microvascular surgeons are desired to keep the ischemia time of viscera to a minimum [11, 12].

Conclusion

Organ-preserving surgeries using microvascular practices represent a promising approach to the management of advanced urological and retroperitoneal malignancies. Its potential to achieve comparable oncological outcomes with minimal complication rates and preserve organ function makes it an attractive option for selected patients. Further research and experience are required to optimise patient selection and refine surgical techniques, ensuring the long-term success of organ-preserving surgeries in such cases.

Author Contribution

Vinay Kant Shankdhar, Dushjant Jaiswal, Mayur Mantri, and Vineet Kumar performed the surgeries. Vinay Kant Shankdhar and Vineet Kumar had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Navneet Kaur, Kunal Mokhale, and Vineet Kumar wrote the manuscript. Vinay Kant Shankhdhar, Ameya Bindu, Saumya Mathews, Amandeep Arora, Gagan Prakash, and Mahendra Pal reviewed the manuscript.

Data Availability

Data can be made available if requested from author.

Declarations

Conflict of Interest

The authors declare no competing interests.