Korean J Urol.  2013 Feb;54(2):78-84.

Simplified Zero Ischemia in Robot Assisted Partial Nephrectomy: Initial Yonsei Experience

Affiliations
  • 1Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea. khrha@yuhs.ac
  • 2Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea.

Abstract

PURPOSE
To evaluate the safety and feasibility of a simplified zero ischemia technique using kidney donor computed tomographic (CT) angiography and conventional laparoscopic bulldog clamps.
MATERIALS AND METHODS
We conducted a review of seven robot-assisted partial nephrectomies (RAPNs) performed by a single surgeon from January 2012 to May 2012. Using a simplified protocol of 3-dimentional reconstruction, tertiary arterial branches supplying the tumor were selectively clamped prior to resection. We used conventional laparoscopic bulldog clamps instead of microsurgical vessel clamps. The patients' demographic information, perioperative outcomes, pathologic outcomes and pre- and postoperative renal functions up to 3 months follow-up were analyzed.
RESULTS
RAPN were successfully performed for seven complex renal hilar tumors. There were no significant differences in the total operation time, estimated blood loss or postoperative outcomes compared with published literature on standard RAPN. Negative surgical margins were reported in all cases.
CONCLUSIONS
We presented a simplified-zero ischemia technique using kidney Donor CT angiography and conventional laparoscopic bulldog clamps. We have also demonstrated its safety and feasibility in patients with complex renal hilar tumors. This modified technique can be easily adopted by most surgeons who are currently performing RAPN.

Keyword

Kidney cancer; Nephrectomy; Robotics; Three-dimensional image

MeSH Terms

Angiography
Follow-Up Studies
Glycosaminoglycans
Humans
Imaging, Three-Dimensional
Ischemia
Kidney
Kidney Neoplasms
Nephrectomy
Robotics
Tissue Donors
Glycosaminoglycans

Figure

  • FIG. 1 Three-Dimensional (3D) reconstruction image from computed tomographic (CT) angiography. (A) Kidney Donor CT angiography for a renal mass that has a PADUA (preoperative aspects and dimensions used for an anatomical) score of 11. (B) 3D reconstitution image (1 mm slice source) showed the tumor-specific tertiary arteries (yellow arrow) with multi directional image (kidney-blue, renal mass-yellow, vessel-red). There is another small tumor-specific first order artery that appeared to supply the tumor, but intraoperative Doppler sonography confirmed that it does not supply the tumour; this artery was not clamped during the operation (blue arrow).

  • FIG. 2 Intraoperative vascular dissection, selection of tumor-specific arterial branches using color Doppler ultrasonography. (A) Tumor feeding artery (yellow arrow) arising from the tertiary order artery (blue arrow). Red arrow indicates the secondary order artery arising from the main renal artery. (B) Intraoperative color-Doppler ultrasound showing the peritumoral Doppler flow (left figure), which decreased (right figure) when the tumor-supplying artery was clamped with laparoscopic bulldog clamps.

  • FIG. 3 Postoperative renal function at 3-month follow-up in patients who underwent simplified zero ischemia robotic partial nephrectomy. eGFR, estimated glomerular filtration rate; Preop, preoperation; Postop, postoperation; POD, postoperative day.


Reference

1. Antonelli A, Zani D, Cozzoli A, Nicolai M, Zanotelli T, Perucchini L, et al. Nephron-sparing surgery versus radical nephrectomy in the treatment of renal cell carcinoma up to 7 cm. Urologia. 2007. 74:173–179.
2. Joniau S, Vander Eeckt K, Srirangam SJ, Van Poppel H. Outcome of nephron-sparing surgery for T1b renal cell carcinoma. BJU Int. 2009. 103:1344–1348.
3. Peycelon M, Hupertan V, Comperat E, Renard-Penna R, Vaessen C, Conort P, et al. Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4 cm. J Urol. 2009. 181:35–41.
4. Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol. 2001. 166:6–18.
5. Simmons MN, Hillyer SP, Lee BH, Fergany AF, Kaouk J, Campbell SC. Functional recovery after partial nephrectomy: effects of volume loss and ischemic injury. J Urol. 2012. 187:1667–1673.
6. Gill IS, Eisenberg MS, Aron M, Berger A, Ukimura O, Patil MB, et al. "Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique. Eur Urol. 2011. 59:128–134.
7. Ng CK, Gill IS, Patil MB, Hung AJ, Berger AK, de Castro Abreu AL, et al. Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy. Eur Urol. 2012. 61:67–74.
8. Jeong W, Park SY, Lorenzo EI, Oh CK, Han WK, Rha KH. Laparoscopic partial nephrectomy versus robot-assisted laparoscopic partial nephrectomy. J Endourol. 2009. 23:1457–1460.
9. Benway BM, Wang AJ, Cabello JM, Bhayani SB. Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes. Eur Urol. 2009. 55:592–599.
10. Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol. 2009. 56:786–793.
11. Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009. 182:844–853.
12. Ljungberg B, Hanbury DC, Kuczyk MA, Merseburger AS, Mulders PF, Patard JJ, et al. Renal cell carcinoma guideline. Eur Urol. 2007. 51:1502–1510.
13. Sutherland SE, Resnick MI, Maclennan GT, Goldman HB. Does the size of the surgical margin in partial nephrectomy for renal cell cancer really matter? J Urol. 2002. 167:61–64.
14. Puppo P, Introini C, Calvi P, Naselli A. Long term results of excision of small renal cancer surrounded by a minimal layer of grossly normal parenchyma: review of 94 cases. Eur Urol. 2004. 46:477–481.
15. Funahashi Y, Hattori R, Yamamoto T, Kamihira O, Kato K, Gotoh M. Ischemic renal damage after nephron-sparing surgery in patients with normal contralateral kidney. Eur Urol. 2009. 55:209–215.
16. Abreu AL, Gill IS, Desai MM. Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU Int. 2011. 108(6 Pt 2):948–954.
17. Rogers CG, Metwalli A, Blatt AM, Bratslavsky G, Menon M, Linehan WM, et al. Robotic partial nephrectomy for renal hilar tumors: a multi-institutional analysis. J Urol. 2008. 180:2353–2356.
18. Simmons MN, Ching CB, Samplaski MK, Park CH, Gill IS. Kidney tumor location measurement using the C index method. J Urol. 2010. 183:1708–1713.
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