The Instrument, Technique, and Philosophy of Extreme Nephron-Sparing Surgery: An Exclusive Interview with Professor Cui Xingang of Xinhua Hospital

Introduction

Urological conditions and related diseases are closely linked to the quality of life of patients worldwide. Innovations in urology encompass multiple domains, including basic research, pharmaceuticals, medical devices, and surgical techniques.

Orange Bureau has launched a special series on urology innovation, aiming to discuss the development and evolution of innovations in urology with clinical experts.

In this episode, we are honored to have Professor Cui Xingang from Shanghai Xinhua Hospital as our guest. As a leading figure in China for nephron-sparing surgery in complex renal tumors, he will share his insights on the instruments, techniques, and philosophy of extreme nephron-sparing surgery.

You open the refrigerator, find an apple that has been stored for a long time, cut it open to discover that the core has turned black, and simply throw it away.

Easy, isn't it?

But if we say that this apple is a kidney, and once discarded, you would have to endure the suffering of uremia and lifelong dialysis to sustain life, would you still throw it away?

You would want to excise the damaged portion.

But through the apple peel, you cannot determine the location, extent, or complexity of the necrotic tissue. You hesitate to resect aggressively, as greater excision leads to greater loss of renal function. You must avoid encroaching upon the margin of the “apple core,” because inadvertent injury to any one of the thousands of blood vessels can cause hemorrhage. And all of this must ideally be completed within 30 minutes.

This is extreme kidney preservation.

As a leading figure in China for maximal nephron-sparing surgery in complex renal tumors, a pioneer in the early adoption of advanced surgical instruments, and a driving force behind increasing the accessibility of nephron-sparing procedures, Director Cui Xingang from Shanghai Xinhua Hospital shares his insights on the “instruments, techniques, and philosophy” of maximal nephron-sparing surgery.

Cui Xingang, Chief Physician, Professor, Doctoral Supervisor, Military Personnel.

Conversations with Cui Xingang were like the goose steps of the PLA: precise, steady, and without any unnecessary fuss.

In 1994, 17-year-old Cui Xingang was admitted to the Second Military Medical University in Shanghai, embarking on a military career that would span several decades. The rigors of military life held few surprises beyond what one might expect: waking at 6 a.m., lights out at 10 p.m., drills such as “at ease,” “attention,” and “forward march,” along with the meticulous arrangement of water bottles, folding stools, and quilt folded into perfect “tofu blocks.”

This day-in, day-out muscle memory has shaped Cui Xingang’s upright posture and the rigor ingrained in his bones.

In 1999, Cui Xingang graduated with a bachelor’s degree and was admitted to graduate school without taking an entrance examination. Two years later, he successfully transitioned from the master’s program to the doctoral program, ultimately becoming one of the few PhD graduates that year to join the staff of Changzheng Hospital, the affiliated hospital.

At that time, the Department of Urology at Changzheng Hospital was already showing a trend toward minimally invasive techniques. Cui Xingang firmly committed to this direction, honing his skills and exploring new technologies over the subsequent two decades. From early practices in laparoscopy to single-port and multi-port approaches, 3D-printed preoperative planning, and surgical robotics, Cui’s pursuit of technical excellence and patient-centered solutions reflected both the mission of a physician and the honor of a soldier.

In clinical practice, Cui Xingang observed a distressing phenomenon. Many patients with renal cell carcinoma undergo "crude and aggressive" surgical resection of a substantial portion or even the entire kidney. Although such destructive surgical procedures are straightforward and convenient, they come at the cost of impaired urinary function for the remainder of the patient’s life, potentially leading to uremia and necessitating regular dialysis, which severely compromises quality of life.

At the Cleveland Clinic’s Glickman Urological & Kidney Institute, widely regarded as one of the world’s leading urology centers, nephron-sparing surgery for renal cell carcinoma is performed in up to 85% of patients. In China, a rate exceeding 60% is already considered favorable, and even at some major medical centers, the figure remains below 40%. This disparity in both clinical philosophy and outcomes is stark and disheartening.

As a physician and soldier, Cui Xingang sought to change this situation.

According to Cui Xingang’s observations, abroad, most nephron-sparing tumor resection procedures are performed using robotic or open surgical approaches, with laparoscopy accounting for a relatively low proportion. In China, due to the limited installed base of surgical robots (fewer than 400 units nationwide), nephron-sparing tumor resections are primarily conducted via laparoscopic or open surgery.

As a surgeon with extensive experience across various surgical modalities, Cui Xinggang has substantial hands-on expertise ranging from open surgery to laparoscopic and robotic-assisted procedures. In his view, despite the objective challenge of higher costs, robotic surgery offers distinct advantages, particularly in achieving maximal nephron-sparing outcomes for complex or ultra-complex renal tumors.

These advantages are primarily reflected in raising the safety ceiling of nephron-sparing surgery. Leveraging the mechanical advantages, robotic arms can rotate and move freely. Within the confined abdominal cavity, this provides sufficient support for surgeons to perform precise resections and suturing. Furthermore, the imaging system achieves a groundbreaking 15x magnification, enabling surgeons to clearly visualize tiny blood vessels under a 3D view. This enhances the accuracy of targeted interventions and reduces the risk of bleeding.

Regarding the user experience with laparoscopy, one limitation is that the magnification is only 5x, resulting in a relatively narrow field of view. Another challenge arises during needle-holding and suturing: since instruments cannot make turns within the abdominal cavity, surgeons must preoperatively calculate the optimal angle and precisely time their movements. While these issues are routine for experienced physicians, they steepen the learning curve for junior doctors.

Each approach has its own indications and usage conditions. Robotic surgery demonstrates significant advantages in ensuring the safety of complex renal tumor procedures, but it is associated with higher costs, and products from different manufacturers still have room for improvement in terms of haptic feedback, force feedback, and dexterity. Laparoscopic surgery offers greater accessibility and benefits from a more extensive accumulation of technical expertise and clinical experience.

Although laparoscopy is sufficiently widespread in terms of hardware and operational experience, this does not mean that our laparoscopic techniques are fully refined.

The opening analogy has already given us a glimpse into the complexity of renal tumor resection. How can one precisely locate and completely excise the tumor, intact and undamaged, from beneath layers of fat, blood vessels, and tissue, while preserving sufficient renal parenchyma? Furthermore, how can vascular occlusion time be strictly controlled to complete the entire procedure—from tumor resection to layered suturing—within 30 minutes?

Cui Xingang has the support of multiple proprietary technologies.

First, preoperative three-dimensional reconstruction of the kidney via imaging modalities and 3D printing enables comprehensive surgical planning, allowing for precise resection while significantly reducing intraoperative time.

Meanwhile, it significantly reduces bleeding time. Within one minute, one-quarter of the body’s blood volume passes through both kidneys, illustrating the substantial magnitude of renal perfusion. Any error during resection or suturing can lead to massive hemorrhage flowing into the bladder via the ureters or extensive oozing within the surgical field. Such significant blood loss places immense psychological pressure on surgeons during the procedure.

Here, Cui Xingang shared an extreme case from his practice: a patient with a solitary left kidney (having undergone prior left nephrectomy) experienced two recurrences in the right kidney, significantly increasing the surgical challenge. To preserve the patient’s only remaining renal function, Cui strictly controlled ischemia time, deviating from the conventional 30-minute benchmark. To this end, Cui and his team employed innovative techniques, including the original “2+1” suturing method and early sequential blood flow restoration, reducing renal ischemia time to just 10 minutes. The patient’s postoperative recovery was smooth. Notably, the team’s original “2+1” suturing technique has been included in the new edition of Wu Jieping Urology.

In addition, the “Sequential Open Blood Flow Method” and the “Non-occlusive Kidney-preserving Surgery with DSA-guided Precise Embolization,” both original innovations of Cui Xingang’s team, have also withstood peer scrutiny in academic circles and clinical practice.

With a wealth of original technologies and endlessly refined skills, Cui Xingang has elevated kidney tumor surgery to a new realm. In one notable procedure, he completed the entire process—from tumor resection to final suturing—in just seven minutes. Like solving a scrambled Rubik’s Cube blindfolded with one hand, he executed every step with ingrained mastery, devoid of any superfluous movements or unnecessary instructions.

"Nothing more than practice makes perfect."

Instruments and techniques are infinitely approaching the theoretical limits in a spiral ascent, but Cui Xingang considers none of these to be the most important.

In Cui Xingang’s view, the most important thing is always the philosophy of surgery.

For a surgeon, even with the assistance of advanced techniques, equipment, and instruments, surgical outcomes may still be suboptimal if their understanding of the disease is insufficient.

For instance, there are multiple options for intraoperative vascular occlusion. Surgeons can employ total occlusion, selective branch occlusion, intermittent occlusion, or the vascular open-flow technique. While these represent novel and advanced innovations, practitioners must clearly understand the appropriate clinical scenarios and, most importantly, the primary objective: ensuring patient safety and therapeutic efficacy.

Another example is the choice of surgical approach. Depending on the tumor’s location within the kidney, an appropriate approach directly determines the duration and difficulty of the surgery, a fact that cannot be altered even by the most advanced instruments. For tumors located in the dorsal upper pole of the kidney, a transabdominal approach obviously adds significant difficulty; for tumors at the ventral renal hilum, a dorsal retroperitoneal approach is likewise suboptimal and unreasonable.

Certainly, the importance of this philosophy is evident not only intraoperatively but also preoperatively. The current consensus in China, based on international guidelines, is that nephron-sparing surgery can be performed for patients with exophytic renal tumors smaller than 4 cm. However, in clinical practice, many patients fall outside these criteria. Some present with rare tumor subtypes; others have a tumor in one kidney and impaired function in the contralateral kidney; some have a solitary kidney; and still others have renal tumors exceeding 4 cm. In Cui Xingang’s view, kidney preservation should be pursued in all these cases. The assessment of indications must also keep pace with advancing medical knowledge.

During the interview, Director Cui Xingang repeatedly emphasized the importance of surgical philosophy. Although he did not explicitly state it, his rigorous demeanor and pursuit of detail reveal a higher guiding principle at heart: prioritizing the well-being of patients.

Every effort he has made since graduation—from mastering theoretical concepts and operating surgical instruments to innovating surgical techniques—has been dedicated to securing, amidst the precarious dance on the edge of a scalpel, the life and dignity that every healthy individual deserves.