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

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

Research output: Contribution to journalArticle

90 Scopus citations

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 4.1 h), median blood loss (200 and 100 ml), 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 1.3 mg/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.

Original languageEnglish (US)
Pages (from-to)67-74
Number of pages8
JournalEuropean urology
Volume61
Issue number1
DOIs
StatePublished - Jan 1 2012

Keywords

  • Laparoscopy
  • Partial nephrectomy
  • Robotic
  • Zero-ischemia

ASJC Scopus subject areas

  • Urology

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    Ng, C. K., Gill, I. S., Patil, M. B., Hung, A. J., Berger, A. K., De Castro Abreu, A. L., Nakamoto, M., Eisenberg, M. S., Ukimura, O., Thangathurai, D., Aron, M., & Desai, M. M. (2012). Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy. European urology, 61(1), 67-74. https://doi.org/10.1016/j.eururo.2011.08.040