Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours
Article first published online: 14 SEP 2011
© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL
Volume 108, Issue 6b, pages 948–954, September 2011
How to Cite
Abreu, A. L.C., Gill, I. S. and Desai, M. M. (2011), Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours. BJU International, 108: 948–954. doi: 10.1111/j.1464-410X.2011.10552.x
- Issue published online: 14 SEP 2011
- Article first published online: 14 SEP 2011
- Accepted for publication 15 July 2011
- robotic partial nephrectomy;
- hilar renal tumours;
- warm ischaemia time;
- vascular micro-dissection;
What's known on the subject? and What does the study add?
Partial nephrectomy is the standard treatment for the surgical small renal mass. Warm ischemia duration is a significant concern during robotic partial nephrectomy that may impact postoperative renal function. Previously we reported our early unclamping technique, that decreased ischemia time to a mean of 14 minutes. Most recently we developed a novel zero-ischemia technique of robotic partial nephrectomy.
We present our novel zero-ischemia technique of robotic partial nephrectomy for technically-challenging hilar tumours. Herein we super-selectively devascularize the tumour by an anatomical vascular microdissection technique, which controls only tumour-specific tertiary or higher-order arterial branches. The renal hilum remains unclamped, thereby eliminating global renal ischemia.
- • Robotic partial nephrectomy (RPN) has emerged as an attractive minimally invasive nephron-sparing surgical option. However, on-going concerns about RPN include: (i) prolonged ischaemia time with potential implications on renal functional outcomes, and (ii) questions about the ability of RPN to address technically challenging hilar tumours.
- • Herein, we detail the technique and present initial perioperative outcomes of our novel technique of zero-ischaemia RPN for complex hilar tumours.
PATIENTS AND METHODS
- • Since May 2010, >100 patients underwent minimally invasive zero-ischaemia PN. Of these, 21 had procedure done robotically. Of these, seven patients had hilar tumours. RPN was offered to all patients irrespective of tumour or reno-vascular anatomy, contralateral kidney characteristics or renal function.
- • Data were prospectively collected and recorded in an Institutional Review Board-approved database.
- • We detail our zero-ischaemia RPN technique and present early perioperative outcomes.
- • Zero-ischaemia RPN was successful in all cases without any hilar clamping. The median (range) tumour size was 4.1 (2.6–6.4) cm and the median RENAL score was 10 (8–10).
- • The warm ischaemia time was zero in all cases.
- • The median (range) operative time was 222 (150–330) min, estimated blood loss was 150 (100–500) mL, and the percentage kidney spared was 75 (50–90)%. The median hospital stay was 4 (3–6) days.
- • There were no intraoperative complications; two patients had postoperative complications (Clavien grade I and II). No patient had a postoperative haemorrhage, urological/renal complication or lost a kidney. All tumour specimens had negative surgical margins on pathology.
- • The median absolute decrease in serum creatinine and estimated glomerular filtration rate at discharge was 0 (0.2–0.7) mg/dL (P = 0.4) and 5 (−16 to 29) mL/min per 1.73 m2 (P = 0.8), respectively.
- • Zero-ischaemia RPN for hilar tumours is safe and feasible and to our knowledge the first report in the literature.
- • Elimination of warm ischaemia may optimally preserve renal function. Prospective randomized studies are needed to confirm any renal functional advantages of clamp-free RPN.
- • Global renal ischaemia appears to be unnecessary during RPN for hilar tumours.