Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative.
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.
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 2.5cm (range: 1–4); operative time was 3h (range: 1.3–6); blood loss was 150ml (range: 20–400); and hospital stay was 3 d (range: 2–19). Nadir mean arterial pressure ranged from 52–65mm Hg (median: 60), typically for 1–5min. 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 (0.9mg/dl and 0.95mg/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.
A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.
Take Home Message
Aiming to completely eliminate renal ischemia during laparoscopic and robotic partial nephrectomy, we report a novel “zero ischemia” technique for substantial renal tumors. Our technique encompasses two fundamental, sequential aspects: (1) selective-branch renal artery/vein microdissection and (2) transient, pharmacologically induced hypotension, timed to precisely coincide with excision of the deep part of the tumor. Fifteen patients underwent the procedure successfully.