Robotic unclamped "minimal-margin" partial nephrectomy: ongoing refinement of the anatomic zero-ischemia concept.

Abstract

BACKGROUND:

Anatomic partial nephrectomy (PN) techniques aim to decrease or eliminate global renal ischemia.

OBJECTIVE:

To report the technical feasibility of completely unclamped "minimal-margin" robotic PN. We also illustrate the stepwise evolution of anatomic PN surgery with related outcomes data.

DESIGN, SETTING, AND PARTICIPANTS:

This study was a retrospective analysis of 179 contemporary patients undergoing anatomic PN at a tertiary academic institution between October 2009 and February 2013. Consecutive consented patients were grouped into three cohorts: group 1, with superselective clamping and developmental-curve experience (n = 70); group 2, with superselective clamping and mature experience (n = 60); and group 3, which had completely unclamped, minimal-margin PN (n = 49).

SURGICAL PROCEDURE:

Patients in groups 1 and 2 underwent superselective tumor-specific devascularization, whereas patients in group 3 underwent completely unclamped minimal-margin PN adjacent to the tumor edge, a technique that takes advantage of the radially oriented intrarenal architecture and anatomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:

Primary outcomes assessed the technical feasibility of robotic, completely unclamped, minimal-margin PN; short-term changes in estimated glomerular filtration rate (eGFR); and development of new-onset chronic kidney disease (CKD) stage >3. Secondary outcome measures included perioperative variables, 30-d complications, and histopathologic outcomes.

RESULTS AND LIMITATIONS:

Demographic data were similar among groups. For similarly sized tumors (p = 0.13), percentage of kidney preserved was greater (p = 0.047) and margin width was narrower (p = 0.0004) in group 3. In addition, group 3 had less blood loss (200, 225, and 150ml; p = 0.04), lower transfusion rates (21%, 23%, and 4%; p = 0.008), and shorter hospital stay (p = 0.006), whereas operative time and 30-d complication rates were similar. At 1-mo postoperatively, median percentage reduction in eGFR was similar (7.6%, 0%, and 3.0%; p = 0.53); however, new-onset CKD stage >3 occurred less frequently in group 3 (23%, 10%, and 2%; p = 0.003). Study limitations included retrospective analysis, small sample size, and short follow-up.

CONCLUSIONS:

We developed an anatomically based technique of robotic, unclamped, minimal-margin PN. This evolution from selective clamped to unclamped PN may further optimize functional outcomes but requires external validation and longer follow-up.

PATIENT SUMMARY:

The technical evolution of partial nephrectomy surgery is aimed at eliminating global renal damage from the cessation of blood flow. An unclamped minimal-margin technique is described and may offer renal functional advantage but requires long-term follow-up and validation at other institutions.

• Authors: Raj Satkunasivam, Sheaumei Tsai, Sumeet Syan, Jean-Christophe Bernhard, Andre Luis de Castro Abreu, Sameer Chopra, Andre K Berger, Dennis Lee, Andrew J Hung, Jie Cai, Mihir M Desai, Inderbir S Gill
• Journal: European urology (Eur Urol) Vol. 68 Issue 4 Pg. 705-12 (Oct 2015) ISSN: 1873-7560 [Electronic] Switzerland
• PMID: 26071789 (Publication Type: Journal Article)
• Copyright: Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Topics

• Adolescent
• Adult
• Aged
• Aged, 80 and over
• Carcinoma, Renal Cell (blood supply, pathology, surgery)
• Constriction
• Feasibility Studies
• Female
• Glomerular Filtration Rate
• Humans
• Ischemia
• Kidney Neoplasms (blood supply, pathology, surgery)
• Length of Stay
• Male
• Middle Aged
• Nephrectomy (adverse effects, methods)
• Operative Time
• Renal Artery (physiopathology, surgery)
• Renal Circulation
• Renal Insufficiency, Chronic (etiology, physiopathology)
• Retrospective Studies
• Risk Factors
• Robotic Surgical Procedures
• Time Factors
• Treatment Outcome
• Tumor Burden
• Young Adult