Editor’s Note:In recent years, new diagnostic and therapeutic innovations in renal cancer have continued to emerge, providing clinicians with a growing range of treatment options. The widespread adoption of robot-assisted partial nephrectomy (RAPN) has enabled patients to achieve both oncological control and functional preservation. During the 2025 Pujiang Uro-Oncology Academic Conference, leading domestic and international experts in uro-oncology gathered to explore cutting-edge advances and surgical innovations in renal cancer. In this interview, Professor Xu Danfeng from Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, shares insights from his team’s pioneering surgical concepts and techniques for managing complex hilar renal tumors, offering valuable perspectives for peers in the field. Hilar Renal Tumors: The Core Challenge in Nephron-Sparing Surgery
With the rise of precision and minimally invasive surgery in urology, nephron-sparing surgery (NSS) has become the standard of care for localized renal tumors. However, a particularly complex subset of tumors — hilar renal tumors — remains one of the most formidable challenges in the field. Due to their proximity to the renal hilum’s “lifeline” — the main renal artery and vein — these tumors are located in an anatomically intricate region where surgical access is limited and resection and reconstruction are technically demanding, placing extremely high demands on the surgeon’s skill and experience.
“First, we must define what we mean by hilar renal tumors,” Professor Xu explained. “These are tumors that, based on imaging, show direct physical contact with the renal artery or vein. The ‘hilar bay’ tumors are even more complex — they occupy the core of the renal hilum, extend across a broad area, and are tightly adherent to major vessels without any normal parenchyma serving as a buffer. This creates a large C-shaped or O-shaped defect after tumor excision, exposing fragile vasculature and the collecting system.”
This distinctive anatomy poses several major surgical challenges:• Complex anatomy and high resection difficulty: The close relationship between the tumor, vasculature, and collecting system makes dissection risky. Inadequate handling may result in uncontrolled bleeding or segmental renal ischemia.• Challenging reconstruction and high suturing risk: The extensive defect and exposed vasculature make reconstruction demanding. Suturing must achieve hemostasis and prevent urine leakage, while avoiding excessive tension or compression that could impair renal function.• High risk of renal function loss: Due to the need for renal artery clamping during such complex procedures, prolonged warm ischemia time can increase the risk of acute kidney injury.• Increased postoperative complications: Compared with non-hilar tumors, these cases are more prone to postoperative bleeding, arteriovenous fistula, or urine leakage, requiring meticulous perioperative management.
TAPD Technology: Redefining Anatomy and Redesigning Surgical Strategy
Instead of being constrained by traditional surgical paradigms, Professor Xu’s team returned to anatomical fundamentals to seek innovation. Through detailed analysis of over 200 cases using 3D reconstructed CTA models and intraoperative findings, they made a groundbreaking discovery: the blood supply of hilar tumors primarily arises from intraparenchymal branches rather than the main hilar vessels. Importantly, there exists a relatively avascular plane between the tumor and the main renal vessels.
Building on this insight, they proposed the Three Anatomical Planes Dissection (TAPD) technique, which divides the hilar tumor resection process into three well-defined surgical layers:• C1 Plane: The interface between the tumor and the main hilar vessels — the critical dissection zone. Because this plane lacks major vascular connections, surgeons can perform sharp, precise dissection to separate the tumor safely from the vessel wall while preserving vascular integrity.• C2 Plane: The surface of the tumor exposed to perirenal fat — the starting point of dissection, which is relatively straightforward.• C3 Plane: The boundary between the tumor and normal renal parenchyma — the main source of intraoperative bleeding, requiring careful enucleation along the pseudocapsule after arterial clamping.
The TAPD approach transforms what was once a complex, uncertain procedure into a systematic, standardized, and reproducible workflow. “We begin by fully mobilizing the kidney to obtain a wide operative field,” Professor Xu explained. “Then we proceed sequentially through the C1, C2, and C3 planes, which minimizes damage to normal tissue, reduces suturing complexity, and allows the resection to be completed efficiently after clamping.”
Personalized Suturing: Simplifying Complexity Through Standardization
“Resection is only half the battle — the other half is suturing well,” Professor Xu emphasized. After removing hilar tumors, surgeons often face large, irregular defects where conventional suturing techniques fall short, leading to prolonged operative times and variable outcomes.
To address this challenge, Professor Xu’s team developed a personalized and patterned suturing strategy based on the geometric characteristics of the defect, simplifying complex reconstruction into three standardized techniques:• VAV Suturing: For wide, flat defects where the transverse diameter exceeds the vertical diameter. Two V-shaped sutures are applied on both sides to reduce lateral tension, while the center is closed using continuous locking stitches.• ARC (Edge-Locking) Suturing: For narrow, elongated defects with a long transverse diameter and limited vertical space, continuous edge-locking sutures provide the fastest and most reliable closure and hemostasis.• VVV (W-Shaped) Suturing: For round or square defects with similar horizontal and vertical dimensions, two consecutive V-shaped stitches form a W pattern, evenly distributing tension and achieving stable closure.
This “suturing formula” allows surgeons to rapidly choose the optimal method according to defect type, greatly shortening suturing time, improving reconstruction quality, and reducing warm ischemia-related renal injury. In a prospective comparative study including 30 hilar and over 170 non-hilar tumor cases, the TAPD technique combined with personalized suturing achieved comparable operative time, blood loss, and perioperative outcomes despite higher anatomical complexity — demonstrating excellent clinical results.
Clinical Outlook
While TAPD and personalized suturing have significantly advanced nephron-sparing surgery for complex hilar tumors, Professor Xu emphasized the continued importance of individualized decision-making. He recalled a recent case in which a patient developed a renal vein tumor thrombus one year after partial nephrectomy, ultimately requiring radical nephrectomy.
“This case highlights a deeper question,” he noted. “Our current progress focuses on how to cut and how to sew, but an equally important question is whether to preserve the kidney at all. If we can develop more precise preoperative assessment tools to predict which technically resectable tumors carry a high risk of recurrence or metastasis, we can make wiser decisions — sparing patients unnecessary reoperations and truly achieving personalized, precision therapy.”
From reinterpreting anatomy to redefining technique — and now to rethinking clinical strategy — Professor Xu Danfeng and his team exemplify not only surgical mastery but also the relentless spirit of scientific exploration. “There is no endpoint in clinical practice — we are always moving forward,” he concluded. This reflection not only encapsulates his philosophy but also symbolizes the boundless potential of China’s contributions to the global field of urologic oncology.
Professor Xu Danfeng
Ruijin Hospital, Shanghai Jiao Tong University School of Medicine
