"Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique

Background

Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative.

Objective

Describe a novel technique of “zero ischemia” laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy.

Design, setting, and participants

Data were prospectively collected into an institutional review board–approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n = 12), RAPN (n = 3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n = 9; 60%), hilar (n = 1), in solitary kidney (n = 1), in patients with chronic kidney disease grade 3 or greater (n = 3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan–Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis.

Measurements

Intraoperative and early postoperative data were collected prospectively.

Results and limitations

All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1–4); operative time was 3 h (range: 1.3–6); blood loss was 150 ml (range: 20–400); and hospital stay was 3 d (range: 2–19). Nadir mean arterial pressure ranged from 52–65 mm Hg (median: 60), typically for 1–5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n = 5) included urine retention (n = 1), septicemia from presumed prostatitis (n = 1), atrial fibrillation (n = 1), urine leak (n = 2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively.

Conclusions

A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.     

Hand-assisted laparoscopic partial nephrectomy without hilar vascular clamping using a saline-cooled, high-density monopolar radiofrequency device

BACKGROUND AND PURPOSE: Nephron-sparing surgery is now accepted as an alternative treatment option for small renal tumors. However, hemostasis during laparoscopic partial nephrectomy can be technically challenging, especially without hilar vascular clamping. The aim of our study was to evaluate the technique of hand-assisted laparoscopic partial nephrectomy using the TissueLink (TissueLink Medical, Dover, NH), a saline-cooled monopolar radiofrequency device, without hilar vascular clamping. PATIENTS AND METHODS: Using the hand-assisted laparoscopic approach, the kidney is mobilized transperitoneally, and the renal tumor with overlying perinephric fat is exposed. The tumor is excised with a 1-cm margin using a combination of the TissueLink device and endoscopic scissors. The tumor and a biopsy of the base of the tumor bed are sent for frozen-section examination. The bleeding vessels are controlled with digital compression and the TissueLink device. At the end of procedure, the tumor bed is covered with a hemostatic agent. Three female and four male patients ages 52 to 76 years (mean 66 years) were treated with this new device for incidental tumors detected during imaging studies (N = 6) or during work-up for gross hematuria (N = 1). Preoperative imaging studies included CT in six patients and MRI in three. The average tumor size was 2.2 cm (range 1.3-3 cm). Only peripheral tumors that did not approach the hilum or the collecting system were selected. RESULTS: All of the patients underwent a hand-assisted laparoscopic partial nephrectomy using the TissueLink device without hilar vascular clamping. There were no intraoperative complications or conversions to open surgery. The mean operative time was 175 minutes, with an estimated blood loss of 186 mL (range 100-300 mL). Histologic examination demonstrated renal-cell carcinoma in five cases, oncocytoma in one, and an angiomyolipoma in one. The dimensions of the normal tissue around the tumor ranged from 1 to 4 mm, and frozen-section analysis showed tumor-free margins in all cases. Postoperatively, all patients recovered well except one patient who developed transient atrial fibrillation, which was treated medically in the immediate postoperative period. All patients were discharged in good condition at an average of 3 days (range 2-6 days). CONCLUSION: Hand-assisted laparoscopic partial nephrectomy without vascular clamping using the TissueLink device is a safe and feasible technique for exclusion of small exophytic renal tissues.     

肾段动脉阻断技术在腹腔镜肾部分切除手术中的应用与技术要点分析（附光盘）

随着小肾癌检出率的增加以及泌尿外科医生对肾脏热缺血损伤认识的提升,肾肿瘤保留。肾单位手术越来越受到业界的关注。腹腔镜下肾段动脉阻断肾部分切除术可以有效地避免正常肾单位的热缺血再灌注损伤。作者重点阐述该技术的各项注意事项和技术要点。     

Potassium-titanyl-phosphate laser laparoscopic partial nephrectomy without hilar clamping in the survival calf model

PURPOSE: Laparoscopic partial nephrectomy (LPN) with hilar clamping represents the various challenges associated with warm ischemia. We tested the feasibility, and acute and chronic outcomes of LPN using a potassium-titanyl-phosphate (KTP) laser without vascular hilar clamping in the survival calf model. MATERIALS AND METHODS: Six Jersey calves weighing 76 to 94 kg underwent a total of 12 staged bilateral transperitoneal laser LPNs of the mid/lower pole using an 80 W KTP laser, including left kidney chronic LPN with 1-month followup in 6 and right kidney acute LPN with immediate sacrifice in 6. Two techniques (ablative vaporization in 5 subjects and wedge resection in 7) were evaluated. Renal parenchymal resection and hemostasis were achieved only with the laser without any adjunctive hemostatic sutures or bioadhesives. Retrograde pyelography, renal arteriography and histological analyses were performed. RESULTS: All 12 procedures were successful performed laparoscopically without open conversion and 11 (92%) were done without hilar clamping. Mean total operative time was 2.9 hours (range 1.5 to 5) and mean blood loss was 119 cc (range 25 to 300). Mean lasing time was 56 minutes (range 20 to 100) with an average energy use of 54 kJ. Mean preoperative and postoperative hemoglobin (10.38 and 10.52 gm/dl) and serum creatinine (0.46 and 0.4 gm/dl, respectively) were similar. At 1-month followup there was no evidence of urinary leakage or arteriovenous fistula. CONCLUSIONS: This initial study of laparoscopic KTP laser partial nephrectomy without hilar clamping confirms its technical feasibility in most cases and good short-term outcomes. This success of laser LPN in the robust survival calf model with its human-sized kidney holds promise for future clinical application.     

Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model

PURPOSE: Hemostasis represents a primary challenge during laparoscopic partial nephrectomy (LPN). We typically clamp the renal artery/vein en bloc and perform LPN expeditiously under warm ischemia conditions. We evaluated Helix Hydro-jet assisted LPN without renal hilar vascular control in the survival calf model. MATERIALS AND METHODS: Staged bilateral LPN using the Hydro-jet was performed without renal hilar vessel control in 10 survival calves (20 kidneys). Parenchymal hydrodissection was performed with a high velocity, ultracoherent saline stream at 450 psi through a small nozzle with integrated suction at the tip. The denuded intrarenal parenchymal blood vessels were precisely coagulated with a BIClamp bipolar instrument and transected. Followup involved biochemical, radiological and histopathological evaluation at designated sacrifice intervals of 1 and 2 weeks, and 1, 2 and 3 months, respectively. RESULTS: All LPNs were completed successfully without open conversion. Of 20 LPNs 18 (90%) were performed without hilar clamping. Pelvicaliceal suture repair was necessary in 5 of 10 chronic kidneys (50%). Mean Hydro-jet(R) partial nephrectomy time was 63 minutes (range 13 to 150), mean estimated blood loss was 174 cc (range 20 to 750) and mean volume of normal saline used for hydro-dissection was 260 cc (mean 50 to 1,250). No animal had a urinary leak. Histological sections from the acute specimen revealed a thin (1 mm) layer of adherent coagulum at the amputation site with minimal thermal artifact. At 2 weeks a layer of adherent fibro-inflammatory pseudomembrane with giant cell reaction was seen. CONCLUSIONS: In this more stringent and robust survival calf model Hydro-jet assisted LPN can be performed without hilar vessel control, thus, completely avoiding warm ischemia. This approach has the potential to decrease the level of technical difficulty inherent in LPN.     

Self-retaining barbed suture during laparoscopic partial nephrectomy

ObjectiveThis study was conducted to investigate the safety and feasibility of self-retaining barbed absorbable suture application in laparoscopic partial nephrectomy (LPN).Materials and methodsFrom January 2010 to September 2014, 38 cases of LPN were performed at Changhua Christian Hospital, Changhua, Taiwan. The patients were divided into two groups: the nonself-retaining barbed suture (non-SRBS) group (n = 21) and the SRBS group (n = 17). There was no significant difference in age, RENAL (Radius, Exophytic/Endophytic properties, Nearness of the tumor to the collecting system or sinus, Anterior/Posterior, Location relative to polar lines) nephrometry score, and tumor type between the two groups. Clinical data and outcomes were analyzed retrospectively.ResultsAll 38 cases of LPN were successfully performed, without conversion to open surgery or serious intraoperative complications. In the SRBS group, renorrhaphy time and length of hospital stay were significantly shorter than those of the non-SRBS group (p = 0.015 and p = 0.009, respectively).ConclusionsThe application of SRBS in LPN could shorten renorrhaphy time and hospital stay with good safety and feasibility.     

Novel technique of knotless hemostatic renal parenchymal suture repair during laparoscopic partial nephrectomy

Free-hand parenchymal suturing during warm-ischemia, laparoscopic partial nephrectomy is a complex and time-sensitive task. We describe a relatively simpler technique of achieving renal parenchymal hemostasis during laparoscopic partial nephrectomy using a polymer self-locking (Hem-o-Lok) clip.