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

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

Research output: Contribution to journalArticlepeer-review

55 Scopus citations

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 150 ml; 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.

Original languageEnglish (US)
Pages (from-to)705-712
Number of pages8
JournalEuropean urology
Volume68
Issue number4
DOIs
StatePublished - Oct 1 2015

Keywords

  • Enucleation
  • Minimal margin
  • Renal cell carcinoma
  • Robotic partial nephrectomy
  • Small renal mass
  • Unclamped partial nephrectomy
  • Zero ischemia

ASJC Scopus subject areas

  • Urology

Fingerprint Dive into the research topics of 'Robotic unclamped "minimal-margin" partial nephrectomy: Ongoing refinement of the anatomic zero-ischemia concept'. Together they form a unique fingerprint.

Cite this