What are the techniques and suture materials required for renorrhapy after partial nephrectomy?

Renorrhapy Techniques and Suture Materials After Partial Nephrectomy

The standard renorrhaphy technique involves collecting system repair with running 2-zero polyglactin suture on a CT-1 needle, followed by parenchymal reconstruction using a modified pledget clip technique with No. 0 polyglactin suture on a CT-X needle reinforced with Hem-o-lok clips and oxidized regenerated cellulose bolsters. 1, 2

Collecting System Repair

When the collecting system is entered during tumor excision (occurring in 57-79% of cases depending on tumor complexity), immediate watertight repair is essential: 1

• Use running 2-zero polyglactin suture on a CT-1 needle to close any caliceal entry 1, 2
• This running closure technique prevents postoperative urinary leakage, which occurs in only 3-4% of cases when properly performed 1

Parenchymal Reconstruction: Modified Pledget Clip Technique

The most widely adopted technique for renal parenchymal closure uses the following specific approach: 1

Suture Preparation

• Pre-prepare a 9-inch No. 0 polyglactin suture on a CT-X needle by placing a knot approximately 2-3 inches from the needle end 1
• Place a Hem-o-lok clip on the suture proximal to the knot on the needle side 1

Suturing Technique

• Pass the suture through the renal parenchyma on one side of the defect 1
• Pull the pledgeted locking clip flush against the renal capsule 1
• Pass the suture over a pre-fashioned, rolled oxidized regenerated cellulose bolster placed in the partial nephrectomy bed 1
• Pass through the opposite side of the renal defect 1
• Cinch the parenchyma tightly against the bolster and secure with a second Hem-o-lok clip 1
• Tie the two free suture ends together over the bolster to reapproximate the defect 1
• Place 3-4 similar parenchymal stitches across the defect until reconstruction is complete 1

Hemostatic Adjuncts

• Apply hemostatic bioadhesive agents over the completed renorrhaphy for additional hemostasis 1

Alternative and Emerging Techniques

Single-Layer vs Double-Layer Closure

Single-layer renorrhaphy is superior to double-layer technique for preserving renal function. 3 A pooled analysis demonstrated that single-layer closure resulted in less GFR decline (-3.19 ml/min) compared to double-layer closure (-6.07 ml/min, p=0.01), supporting the principle that "less is more" for renorrhaphy. 3

Barbed Sutures with Elongated Pledgets

A newer technique uses: 4

• Single layer of monofilament absorbable running barbed sutures to close the renal parenchyma 4
• Reinforced by elongated polytetrafluoroethylene (PTFE) pledgets approximately 8-10 mm in width, cut to match the resection bed 4
• Suture bites placed 3-5 mm apart, with barbed sutures maintaining tension throughout 4
• This technique achieved complete hemostasis in all patients with mean warm ischemia time of 22.5 minutes 4

Running vs Interrupted Sutures

Running sutures appear equivalent to interrupted sutures for functional outcomes, with no significant difference in postoperative GFR decline between techniques. 3 However, running sutures may reduce operative time. 5

Complete Suture Material List

Based on the standard technique, you will need: 1, 2

1. 2-zero polyglactin suture on CT-1 needle - for collecting system repair
2. No. 0 polyglactin suture on CT-X needle (9-inch length) - for parenchymal reconstruction (typically 3-4 sutures needed)
3. Hem-o-lok clips - 6-8 clips (2 per parenchymal suture)
4. Oxidized regenerated cellulose bolsters - rolled to fit the defect
5. Hemostatic bioadhesive agents - for surface application

Critical Technical Considerations

Warm Ischemia Time

Keep warm ischemia time under 25-30 minutes to prevent irreversible renal injury. 1, 2, 6 Prolonged warm ischemia beyond 30 minutes causes irreversible ischemic insult to the kidney. 1

Avoiding Deep Medullary Sutures

Avoid deep medullary sutures as they can damage arcuate arteries and worsen postoperative renal function. 5 Keep suture bites superficial to preserve intrarenal vasculature.

Hilar Control Method

The hilar control technique varies by approach: 1

• Transperitoneal approach: En bloc hilar control with Satinsky clamp 1
• Retroperitoneal approach: Individual vessel control with bulldog clamps (though Satinsky clamp can now be used with experience) 1

Common Pitfalls

• Inadequate collecting system closure leads to urinary leakage (3-4% incidence); ensure watertight running closure 1
• Excessive parenchymal suturing with double-layer technique causes unnecessary functional loss 3
• Prolonged ischemia time during complex renorrhaphy; practice efficiency to stay under 30 minutes 1, 6
• Suture tearing through capsule during knot tying; the Hem-o-lok clips prevent this complication 1