Selective Renal Parenchymal Clamping in Robot-Assisted Laparoscopic Partial Nephrectomy: A Multi-Institutional Experience
ABSTRACT We describe our multi-institutional experience using a laparoscopic clamp to induce selective regional ischemia during robot-assisted laparoscopic partial nephrectomy (RALPN) without hilar occlusion.
A retrospective review of Institutional Revew Board-approved databases of patients who underwent selective regional clamping during RALPN at four institutions was performed.
In 20 patients who were treated for elective indications, RALPN with parenchymal clamping was successful in 17 (85%). Mean age was 63 years (24-78 y). Median tumor diameter was 2.2 cm (1.1-7.2 cm). Mass location was polar in 13 (76%) and interpolar in 4 (24%). Median R.E.N.A.L. nephrometry score was 6 (4-10). Median overall operative time was 190 minutes (129-309 min), while selective clamp time was 26 minutes (19-52 min). Collecting system repair occurred in 8 (47%) patients. No patients needed a blood transfusion. There was no significant difference in preoperative (median 86 mL/min/1.73 m(2)) and immediate postoperative glomerular filtration rate (GFR) (median 78 mL/min/1.73 m(2), P=0.33) or with the most recent GFR (median 78 mL/min/1.73 m(2), P=0.54) at a mean follow-up of 6.1 months (1.2-11.9 mos). Final pathology determination revealed renal-cell carcinoma in 71% with no positive margins on frozen or final evaluation. In three additional patients who were undergoing RALPN, bleeding because of incomplete distal clamp compression necessitated subsequent central hilar clamping for the completion of the procedure.
In our preliminary multi-institutional experience, regional ischemia using a laparoscopic parenchymal clamp is feasible during RALPN for hemostasis. Careful preoperative selection of patients is needed to determine ideal patient and tumor characteristics. Further comparison studies are necessary to determine the true utility of this technique.
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ABSTRACT: The objective of this study was to describe our early experience with robot-assisted partial nephrectomy (RAPN) incorporating selective arterial clamping, using an image overlay navigation system. Three-dimensional images were reconstructed from computed tomography using open source processing software, OsiriX, and were directly visualized on the screen of a da Vinci surgeon's console with TilePro multi-input display functions. Using this imaging system, RAPN with selective arterial clamping was performed in 17 patients with renal tumours. The intraoperative image overlay navigation system made it possible to clearly show the tumour position and vascular supply within the console's field of view, and facilitate selective arterial clamping during RAPN, resulting in a mean decrease in estimated glomerular filtration rates at both 1 and 4 weeks after RAPN < 10 ml/min/1.73 m(2) . RAPN with selective arterial clamping using this innovative imaging system could be a useful alternative to conventional RAPN. Copyright © 2014 John Wiley & Sons, Ltd.International Journal of Medical Robotics and Computer Assisted Surgery 04/2014; 10(4). DOI:10.1002/rcs.1574 · 1.53 Impact Factor
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ABSTRACT: Abstract Objective: To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney. Materials and Methods: The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper. Results: Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23-25 minutes), and the mean blood loss was 110 mL (range, 20-260 mL). Conclusions: This procedure may be a useful option in ischemia for partial nephrectomy.Journal of Laparoendoscopic & Advanced Surgical Techniques 10/2014; 24(11). DOI:10.1089/lap.2014.0212 · 1.19 Impact Factor
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ABSTRACT: Early unclamping of the renal pedicle has been reported to decrease WIT during laparoscopic PN. Our objective was to compare peri-operative outcomes of early unclamping (EU) versus standard unclamping (SU) during robotically assisted partial nephrectomy (RPN). A retrospective multi-institutional study was conducted at eight French academic centres between 2009 and 2013. Patients who underwent RPN for a renal mass were included in the study. Patients without vascular clamping or for whom the decision to perform a radical nephrectomy was taken before unclamping were excluded. Peri-operative outcomes were compared using χ(2) test and Fisher exact tests for discrete variables and Mann-Whitney test for continuous variables. Predictors of WIT and estimated blood loss (EBL) were assessed using multiple linear regression analysis. There were 430 patients: 222 in the EU group and 208 in the SU group. Tumors were larger (35.8 vs. 32.3 mm, p= 0.02) and more complex (RENAL Score: 6.9 vs. 6.1, p<0.0001) in the EU group but surgeons were more experienced (>50 procedures: 12.2% vs. 1.4%, p<0.0001). Mean WIT was shorter (16.7 min vs. 22.3 min, p<0.0001) and EBL was higher (369.5 mL vs. 240 mL, p= 0.001) in the EU group with no significant difference regarding complications or transfusion rates. Those results remained the same when analyzing subgroups of complex renal tumors (RENAL Score ≥ 7) or RPN performed by less experienced surgeons (<20 procedures). In multivariable analysis, EU was predictive of decreased WIT (β=-0.34; p< 0.0001) but was not associated with EBL (β=-0.09, p=0.16). EU can reduce WIT during RPN without increasing morbidity even for complex renal tumours or when being performed by less experienced surgeons.BJU International 04/2014; 114(5). DOI:10.1111/bju.12766 · 3.13 Impact Factor