Partial Nephrectomy Using Renal Artery Perfusion for Cold Ischemia: Functional and Oncologic Outcomes

Vascular injury during laparoscopic partial nephrectomy in a solitary kidney: management, outcome and audit

Background

Vascular injury during laparoscopic partial nephrectomy is a dreadful complication. Though it is a commonly discussed complication, the literature on the circumstances leading to vascular injury, methods of managing the complication and reporting of final outcomes in those cases are limited. We report a case of vascular injury during laparoscopic partial nephrectomy for a hilar tumor in a solitary kidney. We highlight the management of the complication, present the outcome and review the surgical technique.

Case presentation

A 62-year-old male with solitary kidney presented with left renal hilar mass of size 4.4 × 3.8x3.6 cm. The renal nephrometry score was 10ph. The serum creatinine at the time of presentation to the hospital was 1.4 mg/dl. Laparoscopic partial nephrectomy was performed. The patient had severe intraoperative bleeding due to a segmental renal artery injury. The bleeding presented after hilar unclamping and was managed by intracorporeal vascular repair. The blood loss was around 500 ml. The postoperative period was uneventful without the need for hemodialysis. The histopathology report was suggestive of clear cell renal cell carcinoma with negative surgical margin. The follow-up magnetic resonance urogram did not show evidence of any arterial pseudoaneurysm or residual/recurrent tumor. At 18-month follow-up, the serum creatinine was 1.9 mg/dl and the patient did not have any complaints.

Conclusions

Complication of vascular injury while performing laparoscopic partial nephrectomy for complex hilar tumors should be anticipated beforehand. Contingency plans to tackle this complication must be in place before attempting the surgery. Intracorporeal repair of vascular injury during laparoscopic partial nephrectomy is feasible when expertise is available. Low threshold for using endoscopic ultrasound, employing cold ischemia techniques, careful usage of hot cut during tumor resection and complete defatting of the kidney can all be considered ‘safe surgical practices’ during laparoscopic partial nephrectomy for complex hilar tumors. Following aforementioned ‘safe surgical practices’ helps in improving the outcomes and reducing the possibility of complication of vascular injury and helps in managing the complication effectively if it happens despite the precautions.

Renal Function: Implications on the Surgical Treatment of RCC

The good oncologic results after partial nephrectomy for stage 1 RCC show that radical nephrectomy is an overtreatment in most cases, and that many healthy nephrons are removed unnecessarily. However, partial nephrectomy is a difficult operation, with increased blood loss and a higher risk of complications. Therefore, the advantage of preserved function has to be weighed up against the increased trauma of surgery in each individual patient, and the assessment of preoperative function may influence this decision, among other factors such as comorbidities and age. In most studies, renal function has been assessed by means of estimated glomerular filtration rate, and this parameter is very helpful for long-term studies in large populations. However, more precise measurement based on clearance studies are sometimes required for more sophisticated investigations. The technique of partial nephrectomy has evolved substantially in recent years, resulting in the preservation of more nephrons, less damage to the remaining parenchyma, less blood loss, and a decreased risk of complications. The introduction of minimally invasive surgery for this purpose has also decreased the overall morbidity of surgery. In the long-term, chronic kidney disease may result in increased cardiac mortality. There is ongoing discussion on this problem, however, this potential negative influence on overall survival is not only influenced by the rate of renal insufficiency, but also to a great extent by other comorbidities such as hypertension and diabetes. Therefore, in addition to providing the best surgery for any given patient, we have to make sure that the treatment of the comorbidities will also be part of our patient management, since the risk of cardiac failure may be greater than the risk of poor oncologic outcome.

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

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.

Total Intracorporeal Robot Kidney Autotransplantation: Case Report and Description of Surgical Technique

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.

[Three-dimensional spatial measurement versus conventional CT planning in laparoscopic partial nephrectomy for renal tumors]

OBJECTIVE

To analyze the advantages of spatial measurement of anatomical parameters in a 3D model in surgical planning for laparoscopic partial nephrectomy (LPN).

METHODS

From February, 2016 to October, 2017, 37 patients diagnosed with T1 renal mass underwent LPN based on 3D reconstruction after enhanced CT scanning using the Uromedix-3D system (group A), and another 38 patients received LPN with conventional CT planning (group B). The anatomical parameters were measured in the reconstructed 3D model and the demographic data, surgical outcome and postoperative data were compared between the two groups.

RESULTS

In group A, the average time for 3D model reconstruction was (29.3∓9.7) min; the length, width and depth of the renal defect in 3D model were 3.2∓1.1 cm, 2.6∓0.9 cm and 1.7∓0.7 cm, respectively; The distance of the tumor from the collecting system was 3.8∓2.2 mm; The mean R.E.N.A.L score of the patients was 7∓1.5, and 3 patients had accessory renal artery and 2 had early branching of the renal artery. LPNs were completed via the retroperitoneal approach in all the 75 patients without conversion to open or total nephrectomy. Group A and group B showed significant differences in warm ischemic time (26.7∓6.4 vs 31.9∓7.0 min), tumor-excision time (8.4∓2.6 vs 10.4∓2.8 min), renal defect suture time (18.3∓3.9 vs 21.5∓3.4 min), 24-h volume of retroperitoneal drainage (88.6∓40.2 vs 134.3∓58.3 mL) and 48-h volume of retroperitoneal drainage (127.9∓54.5 vs 198.1∓86.3 mL), but not in the demographic data, operation time, intraoperative blood loss or postoperative hospital stay.

CONCLUSIONS

3D reconstruction of the renal masses can be completed efficiently and accurately using this system. Compared with conventional CT-based measurement, 3D spatial measurement of the anatomical structures helps to increase the precision in the performance of LPN and reduce the warm ischemia time.

Completely intracorporeal robotic renal autotransplantation

PURPOSE

We describe a technique of complete intracorporeal renal autotransplantation with donor nephrectomy and transplantation performed in a minimally invasive fashion without extracting the kidney.

MATERIALS AND METHODS

We developed this technique of a completely intracorporeal robotic renal autotransplantation and determined the feasibility of this novel procedure. This includes a method of intracorporeal transarterial hypothermic renal perfusion using a perfusion catheter through a laparoscopic port. The procedure was successfully applied in a 56-year-old man with extensive left ureteral loss after failed ureteroscopy for ureterolithiasis.

RESULTS

Robotic donor nephrectomy was performed with a warm ischemia time of 2.3 minutes. Subsequently cold ischemia was achieved by intracorporeal hypothermic renal perfusion for 95.5 minutes. Vascular anastomoses and ureteroureterostomy in the ipsilateral pelvis were completed after donor nephrectomy with a total overall surgeon console time of 334 minutes. Venous and arterial anastomosis times were 17.3 and 21.3 minutes, respectively. Estimated blood loss was less than 50 ml. There were no complications and the patient was discharged home on postoperative day 1 after normal Doppler transplant renal ultrasound. Postoperative renal scan at 6 weeks, intravenous urogram at 8 weeks and computerized tomography urography at 5 months revealed normal function and successful ureteral reconstruction.

CONCLUSIONS

We report the feasibility of a technique of a completely intracorporeal robotic renal autotransplantation. This operation may be considered in select patients in the hands of experienced robotic surgeons. However, further refinement is required as this novel procedure is cautiously reproduced and adopted by others.

Infrared Thermometer: an accurate tool for temperature measurement during renal surgery

PURPOSE

To evaluate infrared thermometer (IRT) accuracy compared to standard digital thermometer in measuring kidney temperature during arterial clamping with and without renal cooling.

MATERIALS AND METHODS

20 pigs weighting 20Kg underwent selective right renal arterial clamping, 10 with (Group 1 - Cold Ischemia with ice slush) and 10 without renal cooling (Group 2 - Warm Ischemia). Arterial clamping was performed without venous clamping. Renal temperature was serially measured following clamping of the main renal artery with the IRT and a digital contact thermometer (DT): immediate after clamping (T0), after 2 (T2), 5 (T5) and 10 minutes (T10). Temperature values were expressed in mean, standard deviation and range for each thermometer. We used the T student test to compare means and considered p < 0.05 to be statistically significant.

RESULTS

In Group 1, mean DT surface temperature decrease was 12.6 ± 4.1°C (5-19°C) while deep DT temperature decrease was 15.8 ± 1.5 °C (15-18 °C). For the IRT, mean temperature decrease was 9.1 ± 3.8 °C (3-14°C). There was no statistically significant difference between thermometers. In Group 2, surface temperature decrease for DT was 2.7 ± 1.8°C (0-4°C) and mean deep temperature decrease was 0.5 ± 1.0 °C (0-3 °C). For IRT, mean temperature decrease was 3.1 ± 1.9°C (0-6°C). No statistically significant difference between thermometers was found at any time point.

CONCLUSIONS

IRT proved to be an accurate non-invasive precise device for renal temperature monitoring during kidney surgery. External ice slush cooling confirmed to be fast and effective at cooling the pig model.

Current Status of Laparoscopic Partial Nephrectomy

<p>Recently, nephron-sparing, minimally invasive surgery of small renal masses has become popular. The most typical surgery is laparoscopic partial nephrectomy (LPN). However, due to technical difficulties, the indications for LPN had been limited to small, exophytic, and peripheral tumors. This paper introduces current status of oncological outcomes and technical considerations.</p>

Advancements in laparoscopic partial nephrectomy: expanding the feasibility of nephron-sparing

Partial nephrectomy (PN) offers equivalent oncologic outcomes to radical nephrectomy (RN) but has greater preservation of renal function and less risk of chronic kidney disease and cardiovascular disease. Laparoscopic PN remains underutilized likely because it is a technically challenging operation with higher rates of perioperative complications compared to open PN and laparoscopic RN. A review of the latest PN literature demonstrates that recent advancements in laparoscopic approaches, imaging modalities, ischemic mitigating strategies, renorrhaphy techniques, and hemostatic agents will likely allow greater utilization of LPN and expand its usage to increasingly more complex tumors.

Causes of diminished renal function in the affected kidney after partial nephrectomy

OBJECTIVE

To determine the cause of diminished renal function in the affected kidney after partial nephrectomy (PN) for renal tumour, we analyzed the relationship between operative data and postoperative recovery with respect to renal function.

PATIENTS AND METHODS

From May 2005 to December 2010, pre- and postoperative (1 week and 3 months after the procedure) renal function was evaluated by 99mTc- mercaptoacetyltriglycine clearance in 51 patients treated with open partial nephrectomy (OPN; n = 24) and laparoscopic partial nephrectomy (LPN; n = 27). LPN was performed via retroperitoneal (RPLPN; n = 14) or transperitoneal (TPLPN; n = 13) routes. Renal cooling was performed after renal hilar clamping in OPN and RPLPN, although not in TPLPN.

RESULTS

There were 10 patients (two in OPN, six in TPLPN, two in RPLPN) who had diminished renal function in the affected kidney from 1 week to 3 months after PN. Warm ischaemia (versus cold ischaemia; P = 0.017) during renal hilar clamping resulted in diminished renal function. Using multivariate analysis, renal cooling influenced postoperative diminished renal function (P = 0.008).

CONCLUSIONS

Successful preservation of renal function after PN depends on renal cooling during renal hilar clamping. Cold ischaemia for avoiding renal damage is recommended if renal hilar clamping is necessary for tumour extraction.

Renal function and oncologic outcomes after cryoablation or partial nephrectomy for tumors in solitary kidneys

Purpose

Preservation of renal function is of paramount importance in patients with tumors in solitary kidneys. We compared the renal function and oncologic outcomes of patients treated by partial nephrectomy with those of patients treated by cryoablation for solitary kidney tumors.

Materials and Methods

All patients with solitary kidneys who were treated for renal tumors at our institution between 1997 and 2007 were included in the screen. We retrospectively identified 23 patients who underwent cryoablation and 15 patients who underwent partial nephrectomy.

Results

The two groups were similar with regard to age, gender, and tumor laterality. Patients in the partial nephrectomy group had a larger tumor size (3.4 cm vs. 2.5 cm, p=0.01), higher mean estimated blood loss (316 cc vs. 87 cc, p<0.001), longer duration of hospital stay (5.8 vs. 1.8 days, p<0.001), and a higher rate of perioperative complications (53.3% vs. 8.7% patients, p=0.03). Percentage changes in the glomerular filtration rate postoperatively and on follow-up were found to be similar in the two groups. Both the cryoablation and the partial nephrectomy groups with mean follow-ups of 31.2 months and 30.8 months, respectively, had evidence of local or distant recurrence in 3 patients each (13% and 20% respectively, p=0.7). Both groups had a similar mean overall survival (88.9 and 86.9 months in the cryoablation and partial nephrectomy groups, respectively, p=0.8).

Conclusions

For tumors in solitary kidneys, renal functional and clinical outcomes for cryoablation were not significantly different from those for partial nephrectomy. However, cryoablation has the distinct advantage of a lower morbidity rate and can be preferentially offered to selected cases.

Efficacy and safety of nephron-sparing surgery

To analyse the current evidence of efficacy and safety of nephron-sparing surgery (NSS) that encompasses open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN) and robotic partial nephrectomy in the management of localized renal cell carcinoma (RCC). Oncological data, complications and postoperative renal function were reviewed for the most important series of partial nephrectomy. Partial nephrectomy (PN) provides similar oncological control as radical nephrectomy (RN) and is superior to RN with respect to preserving renal function and preventing chronic kidney disease. OPN remains the first treatment option for T1 renal tumors in centers without advanced laparoscopic expertise. Indications for LPN have expanded as such that LPN is suited for most renal tumors provided that the procedure is carried out in selected patients by an experienced laparoscopic surgeon. Warm ischemia time should be kept within 20 min, which is currently recommended regardless of surgical approach. In experienced hands, LPN yields intermediate oncological efficacy and renal function outcome comparable to open surgery in the treatment of pT1 renal tumors. Positive surgical margin rates are comparable after LPN and OPN. In contemporary series, the morbidity of LPN is decreasing to become similar to that of OPN. Preliminary results with robotic PN are comparable to results obtained with LPN. Additional studies are required to validate these results and compare with other current methods, such as thermal ablation. NSS is effective and safe for the management of localized RCC and is the gold standard to which new ablative techniques need to be compared.

Microparticulate ice slurry for renal hypothermia: laparoscopic partial nephrectomy in a porcine model

OBJECTIVES

Previously, we described the feasibility of renal hypothermia using microparticulate ice slurry during laparoscopy. In the present study, we compared surface cooling with the ice slurry versus near-frozen saline or warm ischemia (WI) during laparoscopic partial nephrectomy (LPN) in a porcine model.

METHODS

We used a single-kidney porcine model. Animals in 5 equal groups (n = 6 each) underwent right laparoscopic complete nephrectomy. In Phase I, left LPN was performed under 90 minutes of ischemia and 90-minute renal cooling with either slurry (Slurry group 1) or saline (Saline group 1). No cooling was applied in the WI group. In Phase II, to simulate more extreme condition, ischemia time was extended to 120 minutes and cooling shortened to 10 minutes (Slurry group 2 and Saline group 2). The study endpoints were renal and core temperature during the surgery and serum creatinine at baseline and days 1, 3, 7, and 14 after the procedure.

RESULTS

The ice slurry was easily produced and delivered. Nadir renal temperature (mean ± SD) was 8 ± 4 °C in Slurry group 1 vs. 22.5 ± 3 °C in Saline group 1 (P < .0001). Renal rewarming to 30 °C occurred after 61 ± 7 minutes in Slurry group 2 vs. 24 ± 6 minutes in Saline group 2 (P < .0001). Core temperature decreased on average to 35 °C in the Saline groups compared with 37 °C in the Slurry groups (P < .0001). Serum creatinine did not differ between the Saline and Slurry groups in Phases I and II at any time point.

CONCLUSIONS

Ice slurry provides superior renal cooling compared with near-frozen saline during LPN without associated core hypothermia.

Laparoscopic Partial Nephrectomy Using FloSeal for Hemostasis: Technique and Experiences in 102 Patients

Objectives. The authors report their techniques, perioperative data, and oncological outcome for laparoscopic partial nephrectomy in a single-center experience with 3 different surgeons. Patients and methods. A total of 102 consecutive patients underwent laparoscopic transperitoneal partial nephrectomy for exophytic tumors using FloSeal for hemostasis. Mean age was 58 years (range = 26-79 years), and median tumor size was 2.6 cm (range = 0.5-8.5 cm). In 84 cases, the renal artery was clamped using endoscopic bulldog clamps, and tumor resection was performed using scissors or the harmonic scalpel. Hemostasis was achieved by application of FloSeal; lesions of the collecting system were closed with Lahodny sutures in 33 cases (31%). Frozen sections were obtained for margin status. Results . All 102 procedures were successful with no intraoperative complications. Mean surgical time was 201 minutes (range = 60-355 minutes); clamping time was 25.8 minutes (range = 6-75 minutes) in 64 cases. Margins were negative in 92 cases; in 8 cases secondary resection was necessary to achieve negative margin status, and in 2 cases radical nephrectomy was performed. Histological findings were clear-cell carcinoma in 51 (50.0%), papillary carcinoma in 26 (25.5%), and others in 25 (24.5%) cases. At a mean follow-up of 32 months (12-62 months), no recurrence was observed. Conclusions. Laparoscopic partial nephrectomy with the use of FloSeal is a feasible and safe method for treatment of small renal masses. The technique is reproducible by surgeons who are used to complex laparoscopic procedures. Patient outcome during follow-up was comparable with data published for open standard procedures.