Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

Abstract

BACKGROUND:

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

OBJECTIVE:

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

DESIGN, SETTING, AND PARTICIPANTS:

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011.

INTERVENTION:

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

MEASUREMENTS:

Baseline, perioperative, and postoperative data were collected prospectively.

RESULTS AND LIMITATIONS:

Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size.

CONCLUSIONS:

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

• Authors: Casey K Ng, Inderbir S Gill, Mukul B Patil, Andrew J Hung, Andre K Berger, Andre Luis de Castro Abreu, Masahiko Nakamoto, Manuel S Eisenberg, Osamu Ukimura, Duraiyah Thangathurai, Monish Aron, Mihir M Desai
• Journal: European urology (Eur Urol) Vol. 61 Issue 1 Pg. 67-74 (Jan 2012) ISSN: 1873-7560 [Electronic] Switzerland
• PMID: 21908096 (Publication Type: Journal Article)
• Copyright: Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Topics

• Adult
• Aged
• Blood Loss, Surgical
• Female
• Humans
• Kidney Neoplasms (blood supply, diagnosis, pathology, surgery)
• Laparoscopy (adverse effects)
• Length of Stay
• Los Angeles
• Male
• Microdissection (adverse effects)
• Middle Aged
• Nephrectomy (adverse effects, methods)
• Organ Sparing Treatments (adverse effects)
• Postoperative Complications (etiology)
• Prospective Studies
• Renal Artery (diagnostic imaging, physiopathology, surgery)
• Renal Circulation
• Robotics
• Surgery, Computer-Assisted (adverse effects)
• Time Factors
• Tomography, X-Ray Computed
• Treatment Outcome
• Ultrasonography, Doppler, Color