Selective clamping hand-assisted laparoscopic partial nephrectomy for localized renal tumors: A novel technique.
ABSTRACT: Purpose:In this study, we described our initial experience and analyze the learning curve of segmental renal artery branch clamping with hand-assisted laparoscopic partial nephrectomy (PN) using special instruments. Materials and Methods:We conducted a retrospective review of consecutive cases of hand-assisted laparoscopic PN (LPN) between May 2015 and April 2018. Patient demographics, tumor characteristics, perioperative details, postoperative complications, and warm ischemic time for segmental artery branch clamping were included in our analysis. We used the cumulative sum (CUSUM) method to generate learning curves. Results:Segmental renal artery branch clamping was successfully completed in 16 of 20 patients. The median tumor size was 2.9 cm (range, 1.7-7.0 cm), median operation time was 185 minutes (range, 140-245 minutes), median blood loss was 291 mL (range, 100-600 mL), and median hospital stay was 5 days (range, 4-7 days). The median selective ischemic time was 21 minutes (range, 16-35 minutes). No patient had postoperative complications, acute or delayed bleeding. The median pre- and postoperative serum creatinine levels (0.91 and 0.98 mg/dL, respectively), and the pre- and postoperative estimated glomerular filtration rate (89.7 and 79.6 mL/min per 1.73 m2, respectively) were similar. Upon visual assessment of the CUSUM plots, a downward inflection point for decreasing total operation time was observed in the 9th case and estimated blood loss in the 12th case. Conclusions:Our study shows that segmental renal artery branch clamping hand-assisted LPN for localized renal tumors is feasible, safe, and has a relatively short learning curve.
Project description:<h4>Objective</h4>The aim of this study was to evaluate application of diode laser in laparoscopic partial nephrectomy (LPN), and to question this technique in terms of ease of tumor excision and reduction of warm ischemia time (WIT).<h4>Background data</h4>LPN is the standard operative method for small renal masses. The benefits of LPN are numerous, including preserving renal function and prolonging overall survival. However, reduction of WIT remains main challenge in this operation. In order to shorten WIT, many techniques have been developed, with variable results.<h4>Patients and methods</h4>We performed a prospective collection and analysis of health records for patients who were operated on between March 2011 and August 2012. Inclusion criteria were single tumor ? 4 cm, predominant exophytic growth and intraparenchymal depth ? 1.5 cm, with a minimum distance of 5 mm from the urinary collecting system.<h4>Results</h4>We operated on 17 patients. Median operative time was 170 min. In all but two patients, we had to perform hilar clamping. Median duration of WIT was 16 min. Pathohistological evaluation revealed clear cell renal cancer and confirmed margins negative for tumor in all cases. Median size of the tumor was 3 cm. Median postoperative hospitalization was 5 days. Average follow up was 11.5 months. There were no intraoperative complications. One postoperative complication was noted: perirenal hematoma.<h4>Conclusions</h4>Laser LPN is feasible, and offers the benefit of shorter WIT, with effective tissue coagulation and hemostasis. With operative experience and technical advances, WIT will be reduced or even eliminated, and a solution to some technical difficulties, such as significant smoke production, will be found.
Project description:BACKGROUND:To assess the safety, tumor control and renal function preservation of the emergency retroperitoneal laparoscopic partial nephrectomy (LPN) for ruptured renal angiomyolipoma (AML) and summarize our single-center initial experience. METHODS:We performed a retrospective analysis of 15 patients pathologically confirmed renal AML treated with emergency retroperitoneal LPN between January 2016 and May 2019. The patient demographics, operation time, blood loss, transfusion requirements, complications and other surgical parameters were analyzed. Follow-up was performed by serum creatinine and imaging modalities. RESULTS:Fifteen patients were performed with emergency LPN with the median age 41.6?years. The mean size of the renal AMLs was 7.8?cm. The mean size of the retroperitoneal hematomas was 8.5?cm. All the emergency surgeries were performed successfully without any conversion to nephrectomy or open surgery. The mean operative time was 101?min. The mean warm ischemia time was 28?min. The mean estimated blood loss was 311?ml. Five patients required intraoperative blood transfusion (33.3%, 5/15). The mean transfused RBC was 4?U (range 2-6?U), and the mean transfused plasma was 200?ml (range 200-400?ml). The mean drainage duration was 3?days (range 2-5?days). The mean postoperative hospitalization was 4.7?days. No patients experienced intraoperative complications. The mean serum creatine was slightly higher after surgery (53.1 vs. 55.9??mol/L). One patient had postoperative perirenal fluid collection. No patients needed dialysis. No recurrence was observed in the patients at the median follow-up of 24.1?months. CONCLUSIONS:Our initial experience shows that the emergency retroperitoneal LPN is a safe, minimally invasive procedure for emergency patients with ruptured renal AMLs. It could be considered as an effective alternative to renal artery embolization in selected emergency patients.
Project description:OBJECTIVE: The purpose of our study was to assess the extrarenal length of renal arterial branches and tumour-feeding arteries on multidetector CT (MDCT) angiography, in addition to the perihilar branching patterns, with relevance to segmental artery clamping. METHODS: MDCT angiograms of 64 patients with renal masses <4 cm were retrospectively reviewed by 2 radiologists. The perihilar branching patterns of the single main renal artery were assessed according to the number of pre-segmental and segmental arteries. The extrarenal lengths of segmental plus pre-segmental arteries and the tumour-feeding arteries, measured on volume-rendered images, were compared according to the vascular segmentation and the tumour location, respectively. RESULTS: In the 116 kidneys, 1 pre-segmental plus 5 segmental arteries (n=48) was the most common branching pattern. The mean extrarenal length of the inferior segmental plus pre-segmental arteries (33.05 mm) and the posterior segmental plus pre-segmental arteries (32.30 mm) was longer than any of the other segmental plus pre-segmental arteries (apical, 23.87 mm; superior, 26.80 mm; middle, 29.23 mm) (p<0.05). The mean extrarenal length of the lower pole tumour-feeding arteries (35.94 mm) was longer than those of the upper and mid-pole tumour-feeding arteries (24.95 mm, 29.62 mm), with significant difference between the lower and the upper pole tumour-feeding arteries (p<0.05). CONCLUSION: Tumours in the lower pole, supplied by the inferior or posterior segmental artery, may be more amenable to segmental artery clamping. ADVANCES IN KNOWLEDGE: MDCT angiography with volume rendering can demonstrate the extrarenal length of tumour-feeding arteries and may help in determining the accessibility for segmental artery clamping.
Project description:<h4>Background</h4>To assess the technical feasibility and outcomes of robotic-assisted partial nephrectomy (RPN) with sequential segmental renal artery (SRA) clamping for multiple ipsilateral renal tumors (MIRTs).<h4>Methods</h4>From April 2016 to February 2018, consecutive eleven cases successfully underwent RPN with sequential SRA clamping under the guidance of dual-source computed tomography (DSCT).<h4>Results</h4>Ten cases had two lesions and two cases had three at the ipsilateral kidneys. The mean size and the mean R.E.N.A.L score for the dominant lesion of single case were 3.3?cm and 5.7, respectively. Twenty-two lesions (84.6%) had one target SRA and four (15.4%) had two target SRAs. Satisfactory ischemic areas were achieved by sequentially clamping two (81.8%) or three (18.2%) target SRAs with mean clamping time of 18.8 (15.0-27.0) min for single lesion, and the mean of total clamping time for single case was 37.5 (32.0-52.0) min. Only the complications of grade 1-2 were found and no positive surgical margin was discovered. The mean follow-up time was 5.4?months and no local recurrence or metastasis was found. The mean postoperative eGFR was 71.2?ml/minute/1.73m<sup>2</sup> that was only an insignificant reduction (9.3%) compared with the preoperative baseline.<h4>Conclusion</h4>This novel nephron-sparing technique, RPN with sequential SRA clamping, represents a good alternative for selected patients with MIRTs. With the guidance of DSCT and skilled robotic experience, this technique is feasible and can maximize renal function preservation. Large-scale multicenter clinical studies are still needed to further prove these initial outcomes.
Project description:Objective:Internal iliac artery (IIA) preservation is associated with improved outcomes after both open and endovascular aortoiliac aneurysm repair. Total robotic laparoscopic repair of aortoiliac aneurysms has been reported in the past, but not in combination with sutureless anastomosis applied to the IIAs. The objective of this study was to demonstrate the feasibility of the total robotic laparoscopic technique including a method of deploying the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) using robotic instruments. Methods:Between June 2015 and December 2016, four patients underwent total robotic laparoscopic repair of isolated common iliac artery (CIA) aneurysms. Two patients had unilateral aneurysms and two had bilateral aneurysms. Unilateral CIA aneurysms were treated with a graft from the proximal CIA to the proximal external iliac artery, and bilateral CIA aneurysms were treated with a bifurcated graft between the distal aorta and both proximal external iliac arteries. The nitinol reinforced section of the GHVG was then inserted and deployed into the corresponding IIA, and the nonreinforced segment was sewn in an end-to-side fashion to the iliac graft. Results:The median age of patients was 55.5 years (range, 48-64 years); median body mass index was 24.9 kg/m2 (range, 23-26.4 kg/m2). All four cases were technically successful. Operative times were 325 and 332 minutes for unilateral cases and 491 and 385 minutes for bilateral cases. For the entire series, median proximal clamping time was 143 minutes (range, 110-163 minutes), and the median time to deploy the GHVG was 15 minutes (range, 8-27 minutes). The median estimated blood loss was 1800 mL (range, 800-2100 mL). Intraoperative cell salvage was used in all cases. No intraoperative or postoperative complications occurred. No patient required blood transfusion. All patients tolerated a regular diet on postoperative day 2 and were discharged on postoperative day 4. Patients returned to work and full physical activity within 6 weeks (range, 2-6 weeks). At 6-month follow-up, computed tomography angiography demonstrated 100% patency of iliac artery grafts as well as of the GHVGs. Conclusions:Total robotic laparoscopic CIA aneurysm repair is feasible in both unilateral and bilateral cases in carefully selected patients. The GHVG can be successfully deployed using robotic technique for IIA preservation during total robotic CIA aneurysm repair.
Project description:Objective: To investigate predictors of acute kidney injury (AKI) following open aortic repair (OAR) requiring suprarenal clamping. Methods: The study included 833 nonhemodialysis patients who had undergone elective OAR (with suprarenal clamping, n=73; with infrarenal clamping, n=760). We evaluated AKI as defined by the criteria of the Kidney Disease Improving Global Outcomes (KDIGO) and compared in-hospital outcomes between the two groups. We also investigated the effects of AKI on outcomes, factors related to post-suprarenal clamping AKI, and efficacy of hypothermic renal perfusion (HRP) in the suprarenal clamping group. Results: For the suprarenal vs. infrarenal clamping group, in-hospital mortality was 0% (0/73) vs. 0.5% (4/760). The incidence of AKI was greater in the suprarenal clamping group (37% vs. 15%, P<0.001), and the hospital stay for patients with AKI was longer than for those patients without AKI (median, 21 days vs. 16 days; P=0.005). Renal ischemia time and bleeding volume >1,000?mL were associated with post-suprarenal clamping AKI. Renal ischemia time was longer with HRP (n=15) than without HRP (n=58) (median, 51?min vs. 33?min; P=0.011), and HRP did not decrease the incidence of AKI (40% vs. 36%; P=0.78). Conclusion: Prolonged renal ischemia and substantial intraoperative bleeding are associated with postoperative AKI following suprarenal clamping.
Project description:Introduction:Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).Methods:A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review.Results:Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN.Conclusions:Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.
Project description:Laparoscopic Partial Nephrectomy (LPN) after intra-arterial Embolization of renal tumors (LPNE) in a hybrid operating room allows renal tumor enucleation without dissection and clamping of the renal pedicle. The purpose was to assess the potential negative impact of embolization on the renal function. This prospective monocentric study included all patients treated with LPNE between May 2015 and June 2019. Clinical data was collected and incorporated into the UroCCR database (NCT03293563). Glomerular Filtration Rate (GFR) and Computed Tomography Renal Volume (CTRV) were compared before and after 6 months following LPNE. The mean post-operative GFR was 86.6 mL/min (SD 22.9). The mean GFR loss was 9.4% (SD 15.1) and the median renal parenchyma loss was 21 mL (SD 20.6). Using a threshold of 25% GFR loss, age was the only significant predictive factor of renal function impairment according to bivariate (59.5 vs 69.3 years, p?=?0.017) and multivariable analysis (OR 1.075, CI 1-1.2], p?=?0.05). Significant renal function impairment was not correlated with the renal parenchymal volume loss (OR 0.987, CI [0.95-1.02], p?=?0.435). Renal function impairment after LPNE seems to be comparable to other techniques of partial nephrectomy.
Project description:INTRODUCTION:Renal ischaemia reperfusion injury is an inevitable pathophysiology in different clinical situations including laparoscopic partial nephrectomy (LPN), which can obviously decrease the renal function after surgery. Pneumoperitoneum preconditioning (PP) is a promising approach that can yield a protective effect on kidney, which has already been demonstrated in some animal models. The present study is designed to assess whether the PP can yield a clinical renoprotective role after LPN. METHODS AND ANALYSIS:This study is a randomised, prospective, double-blind and parallel controlled clinical trial. Eligible participants will be patients with renal tumours and willing to choose elective LPN. Patients randomised to the treatment arm will receive PP consisted of three cycles of 5?min insuf?ation and 5?min desuf?ation before LPN, while the control arm will receive a sham operation. The primary endpoints are glomerular filtration rate and the level of serum cystatin C within 6 months after desuf?ation. The secondary endpoints are serum creatinine, estimated glomerular filtration rate, alanine transaminase, serum amylase, intestinal fatty acid binding protein, postoperative hospital stay, the incidence of adverse events and mortality in postoperative 6 months. ETHICS AND DISSEMINATION:This study has been approved by the institutional ethics committee of Nanjing First Hospital. The results of this study will be reported faithfully through scientific conferences or published articles. TRIAL REGISTRATION NUMBER:NCT03822338.
Project description:Posterior hilar renal tumor extirpation by partial nephrectomy is a unique challenge for transperitoneal laparoscopy. We describe our novel technique of "polar flip" for these tumors. Kidney is rotated by around 45 -60 degrees after mobilisation so that lower pole faces anteriorly and upper pole faces posteriorly, thereby exposing the posterior surface for maneuverability. Technical highlights are hilar control, complete kidney mobilisation, initial flipping with dissection in Gil Vernet's plane to clip posterior segmental renal artery, en mass hilar clamping in normal lie, polar flipping, dissection in Gil Vernet's plane till renal sinus fat, completion of tumor excision, selective vascular ligation, renorhaphy and nephropexy.