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De Backer P, Vangeneugden J, Berquin C, Vermijs S, Dekuyper P, Mottrie A, Debbaut C, Quackels T, Van Praet C, Decaestecker K. Robot-assisted Partial Nephrectomy Using Intra-arterial Renal Hypothermia for Highly Complex Endophytic or Hilar Tumors: Case Series and Description of Surgical Technique. EUR UROL SUPPL 2023; 58:19-27. [PMID: 38028235 PMCID: PMC10660005 DOI: 10.1016/j.euros.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background In partial nephrectomy for highly complex tumors with expected long ischemia time, renal hypothermia can be used to minimize ischemic parenchymal damage. Objective To describe our case series, surgical technique, and early outcomes for robot-assisted partial nephrectomy (RAPN) using intra-arterial cold perfusion through arteriotomy. Design setting and participants A retrospective analysis was conducted of ten patients with renal tumors (PADUA score 9-13) undergoing RAPN between March 2020 and March 2023 with intra-arterial cooling because of expected arterial clamping times longer than 25 min. Surgical procedure Multiport transperitoneal RAPN with full renal mobilization and arterial, venous, and ureteral clamping was performed. After arteriotomy and venotomy, 4°C heparinized saline is administered intravascular through a Fogarty catheter to maintain renal hypothermia while performing RAPN. Measurements Demographic data, renal function, console and ischemia times, surgical margin status, hospital stay, estimated blood loss, and complications were analyzed. Results and limitations The median warm and cold ischemia times were 4 min (interquartile range [IQR] 3-7 min) and 60 min (IQR 33-75 min), respectively. The median rewarming ischemia time was 10.5 min (IQR 6.5-23.75 min). The median pre- and postoperative estimated glomerular filtration rate values at least 1 mo after surgery were 90 ml/min (IQR 78.35-90 ml/min) and 86.9 ml/min (IQR 62.08-90 ml/min), respectively. Limitations include small cohort size and short median follow-up (13 [IQR 9.1-32.4] mo). Conclusions We demonstrate the feasibility and first case series for RAPN using intra-arterial renal hypothermia through arteriotomy. This approach broadens the scope for minimal invasive nephron-sparing surgery in highly complex renal masses. Patient summary We demonstrate a minimally invasive surgical technique that reduces kidney infarction during complex kidney tumor removal where surrounding healthy kidney tissue is spared. The technique entails arterial cold fluid irrigation, which temporarily decreases renal metabolism and allows more kidneys to be salvaged.
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Affiliation(s)
- Pieter De Backer
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent, Belgium
- IBiTech-Biommeda, Department of Electronics and Information Systems, Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
- ORSI Academy, Melle, Belgium
| | - Joris Vangeneugden
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent, Belgium
| | - Camille Berquin
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent, Belgium
| | - Saar Vermijs
- IBiTech-Biommeda, Department of Electronics and Information Systems, Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | - Peter Dekuyper
- Department of Urology, AZ Maria Middelares Hospital, Ghent, Belgium
| | - Alexandre Mottrie
- ORSI Academy, Melle, Belgium
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Charlotte Debbaut
- IBiTech-Biommeda, Department of Electronics and Information Systems, Faculty of Engineering and Architecture, Ghent University, Ghent, Belgium
| | | | - Charles Van Praet
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent, Belgium
| | - Karel Decaestecker
- Department of Urology, ERN eUROGEN Accredited Centre, Ghent University Hospital, Ghent, Belgium
- Department of Urology, AZ Maria Middelares Hospital, Ghent, Belgium
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Zhu C, Yin H, Zhao S, Ma Y, Sun Z, Zhu M, Du Z, Yang T. Clinical study of renal artery cold perfusion combined with laparoscopic nephron retention in the treatment of complex renal angiomyolipoma. Front Oncol 2023; 13:1220380. [PMID: 37920170 PMCID: PMC10619158 DOI: 10.3389/fonc.2023.1220380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/27/2023] [Indexed: 11/04/2023] Open
Abstract
Objective The aim of this study is to summarize the surgical experience of renal artery cold perfusion combined with laparoscopic nephron preserving surgery for the treatment of complex renal angiomyolipoma and to evaluate the safety and feasibility of this surgical protocol. Materials and methods Clinical data of nine patients who received renal artery cold perfusion combined with laparoscopic nephron preserving surgery for complex renal angiomyolipoma in our hospital from February 2017 to August 2020 were retrospectively analyzed. The study parameters included imaging findings, total renal function before and after surgery, glomerular filtration rate (GFR) of affected kidney before and after surgery, and related complications. Results Eight of the nine patients successfully completed the operation, one patient was intolerant to renal artery balloon implantation, and the success rate of the operation was 88.89%. The mean maximum tumor diameter was 6.8 cm, and RENAL score was 7 points. Postoperative total renal function and GFR of the affected kidney had no significant changes compared with that before surgery, and imaging examination showed no tumor residue or recurrence. Conclusion This surgical procedure is safe and feasible for complex renal angiomyolipoma and can be used as a surgical option for renal hamartoma. The long-term effect needs to be confirmed by further studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Tiejun Yang
- Department of Urology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, China
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Bai Y, Yang Y, Wei H, Quan J, Wei F, Zhang Q, Liu F. Clinical outcomes of robotic-assisted laparoscopic partial nephrectomy with renal hypothermia perfusion by renal artery balloon catheter in treating patients with complex renal tumors. Front Oncol 2022; 12:918143. [PMID: 36091113 PMCID: PMC9459104 DOI: 10.3389/fonc.2022.918143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/18/2022] [Indexed: 12/09/2022] Open
Abstract
Objective This study aimed to investigate the safety and efficacy of renal hypothermic perfusion by renal artery balloon catheter during robot-assisted laparoscopic partial nephrectomy (P-RALPN) for patients with complex renal tumors. Materials and methods We retrospectively identified 45 patients with complex renal tumors who received standard robot-assisted laparoscopic partial nephrectomy (S-RALPN) and 11 patients treated with P-RALPN from September 2017 to October 2021. Preoperative patients’ characteristics and intraoperative surgical parameters including operating time, blood loss, hospitalization, pre- and post-surgical glomerular filtration rate (GFR), and postoperative survival time were collected and compared between the two groups. The patients’ body temperature, real-time kidney temperature, and short-term renal function were analyzed in the P-RALPN group. Results There was no statistically significant difference on median intraoperative estimated blood loss and postoperative hospitalization between the two groups. Patients who received P-RALPN had a slightly longer operative time than those who received S-RALPN (103.1 versus 125.9; p = 0.09). In the P-RALPN group, the volume of perfusion solution was 533.2 ml (range, 255.0–750.0 ml), the median temperature of kidney was 22.6°C (range, 21.7–24.1°C) after the kidney cools down, and the median minimum intraoperative temperature of patients was 36.1°C (range 35.2–36.7°C). The ischemia time in the S-RALPN group was markedly lower than that in the P-RALPN group (21.5 versus 34.8; p < 0.01). However, the loss of GFR was much higher for the S-RALPN group after the surgery. (28.9 versus 18.4; p < 0.01). Importantly, patients had similar postoperative survival time between the two groups (p = 0.42; HR = 0.27). Conclusion P-RALPN is a safe and feasible surgery in the treatment of patients with complex renal tumors, which provides a new operative approach for clinicians to treat these patients.
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Affiliation(s)
- YuChen Bai
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - YunKai Yang
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - HaiBin Wei
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Jing Quan
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Fei Wei
- Graduate Department, Bengbu Medical College, Bengbu, China
| | - Qi Zhang
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
- *Correspondence: Feng Liu, ; Qi Zhang,
| | - Feng Liu
- Urology and Nephrology Center, Department of Urology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, China
- *Correspondence: Feng Liu, ; Qi Zhang,
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Lu Q, Zhao X, Ji C, Guo S, Qiu X, Liu G, Zhang S, Li X, Zhang G, Zhang X, Guo H. Functional and oncologic outcomes of robot-assisted simple enucleation with and without renal arterial cold perfusion in complex renal tumors: a propensity score-matched analysis. BMC Urol 2021; 21:2. [PMID: 33407361 PMCID: PMC7789613 DOI: 10.1186/s12894-020-00771-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 12/09/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND To compare robot-assisted simple enucleation with renal arterial cold perfusion (RACP-RASE) and RASE alone in complex renal tumors with regard to perioperative, functional and oncologic outcomes by propensity score-matched analysis. METHODS Data from 351 patients who underwent RACP-RASE or RASE for complex renal tumors were recorded between September 2014 and December 2017. Propensity score-matched analysis was performed on age, sex, BMI, ECOG score, tumor side and size, preoperative estimated glomerular filtration rate (eGFR), RENAL score and PADUA score. RESULTS The study included 31 RACP-RASE and 320 RASE procedures. RENAL score and PADUA score were higher and tumor diameter was greater under RACP-RASE than RASE. After matching, the two groups were similar in estimated blood loss (208.3 vs 230.7 ml; p = 0.696) and ischemic time (34.8 vs 32.8 min; p = 0.342). The RACP-RASE group had significantly longer operative time than the RASE group (264.1 ± 55.7 vs 206.9 ± 64.0 min, p = 0.001). There was no difference in the incidence of postoperative complications between the two groups (13.8% vs 24.1%; p = 0.315), as was the overall incidence of positive surgical margins (3.4 vs 0%; p = 1.000). The changes in eGFR significantly differed between the two groups at 3 months (p = 0.018) and 12 months (p = 0.038). More patients in the RASE group were CKD upstaged (p = 0.043). At multivariable analysis, preoperative eGFR and the type of procedure were significant predictive factors for a change of more than 10% in eGFR at 3 months postoperatively. There was no local recurrence or distant metastasis during follow-up. CONCLUSIONS RACP-RASE is an effective and safe technique for complex renal tumors that can provide appropriate temporary arterial occlusion and renal hypothermic perfusion. Renal arterial cold perfusion may be helpful in protecting renal function in RASE as compared with warm ischemia.
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Affiliation(s)
- Qun Lu
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Xiaozhi Zhao
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Changwei Ji
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Suhan Guo
- School of Public Health, Nanjing Medical University, Nanjing, 210029, Jiangsu, People's Republic of China
| | - Xuefeng Qiu
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Guangxiang Liu
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Shiwei Zhang
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Xiaogong Li
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Gutian Zhang
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China
| | - Xuebin Zhang
- Department of Radiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, 210008, Jiangsu, People's Republic of China
| | - Hongqian Guo
- Department of Urology, Drum Tower Hospital, Medical School of Nanjing University, Institute of Urology, Nanjing University, 321 Zhongshan Rd., Nanjing, 210008, Jiangsu, People's Republic of China.
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Van Praet C, Lambert E, Desender L, Van Parys B, Vanpeteghem C, Decaestecker K. Total Intracorporeal Robot Kidney Autotransplantation: Case Report and Description of Surgical Technique. Front Surg 2020; 7:65. [PMID: 33425979 PMCID: PMC7786393 DOI: 10.3389/fsurg.2020.00065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/05/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction and Objectives: Kidney autotransplantation can be performed in patients with complex renal or ureteral pathology not suitable for in situ reconstruction, such as renal vasculature anomalies, patients with proximal or long complex ureteral strictures, or complex oncological cases. Robot-assisted surgery allows for a high-quality vascular and ureteral anastomosis and faster patient recovery. Robot-assisted kidney autotransplantation (RAKAT) is performed in two phases: nephrectomy and pelvic transplantation. In-between, extraction of the kidney allows for vascular reconstruction or kidney modification on the bench and safe cold ischemia can be established. If no bench reconstruction is needed, total intracorporeal RAKAT (tiRAKAT) is feasible. One case report in Europe has been described; however, to our knowledge no surgical video is available. Methods: A 58 year-old woman suffered from right mid- and distal ureteral stenosis following pelvic radiotherapy 10 years prior for cervical cancer. A JJ stent was placed, but she suffered from recurrent urinary tract infections, and ultimately a nephrostomy was placed. Renogram demonstrated 43% relative right kidney function. As her bladder volume was low following radiotherapy, no Boari flap was possible and the patient refused life-long nephrostomy or nephrectomy. Therefore, tiRAKAT was performed using the DaVinci Xi system. Results: We describe our surgical technique including a video. Surgical time (skin-to-skin) was 5 h and 45 min. Warm ischemia time was 4 min, cold ischemia 55 min, and rewarming ischemia 15 min. The abdominal catheter and bladder catheter were removed on the first and second postoperative day, respectively. The JJ stent was removed after 4 weeks. The patient suffered from pulmonary embolism on the second postoperative day, for which therapeutic low molecular weight heparin was started. No further complications occurred during the first 90 postoperative days. After 7 months, overall kidney function remained stable, right kidney function dropped non-significantly from 27 to 25.2 mL/min (−6.7%) on renal scintigraphy. Conclusion: We demonstrated feasibility and, for the first time, a surgical video of tiRAKAT highlighting patient positioning, trocar placement, and intracorporeal cold ischemia technique.
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Affiliation(s)
| | - Edward Lambert
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Liesbeth Desender
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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Eich C, Giessing M. [Radical nephrectomy and partial nephrectomy]. Aktuelle Urol 2020; 51:441-449. [PMID: 32722827 DOI: 10.1055/a-1190-3102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Renal cell carcinoma is the 2nd most frequent urological malignancy in women and the third most frequent in men, with an age peak in the seventh decade of life. If detected early in a local non-metastatic stage, options for complete recovery are excellent. While two decades ago, even locally limited cancers of the kidney were cured by radical nephrectomy, treatment today mostly consists of local treatment for locally confined cancers. Guidelines today recommend local surgical excision (open or minimally-invasive) or - in selected cases - topical energy application (radio-frequency ablation, cryoablation). The surgeon's expertise is most important in the selection of the appropriate kind of surgery and different guidelines have slightly different recommendations.Treatment decisions should be made on an individual basis in due consideration of an individual's age and co-morbidities. This may lead to the recommendation that, due to low perioperative morbidity, even localised carcinomas should be treated by (minimally-invasive) radical nephrectomy instead of nephron-sparing surgery and, in other cases, a non-interventional, active surveillance strategy may be pursued without compromising the patient's life expectancy. For higher-grade renal cell carcinomas, there is usually an indication for radical nephrectomy, as long as no metastases are detected. This also applies to carcinomas with venous thrombi extending into the atrium of the heart. Complications in the treatment of renal carcinomas are usually rare and easily treatable in most cases.
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Affiliation(s)
| | - Markus Giessing
- Universitätsklinikum Düsseldorf, Klinik für Urologie, Düsseldorf
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