Zero‐ischaemia robotic partial nephrectomy (RPN) for hilar tumours

Abstract

What's known on the subject? and What does the study add? Partial nephrectomy is the standard treatment for the surgical small renal mass. Warm ischemia duration is a significant concern during robotic partial nephrectomy that may impact postoperative renal function. Previously we reported our early unclamping technique, that decreased ischemia time to a mean of 14 minutes. Most recently we developed a novel zero‐ischemia technique of robotic partial nephrectomy. We present our novel zero‐ischemia technique of robotic partial nephrectomy for technically‐challenging hilar tumours. Herein we super‐selectively devascularize the tumour by an anatomical vascular microdissection technique, which controls only tumour‐specific tertiary or higher‐order arterial branches. The renal hilum remains unclamped, thereby eliminating global renal ischemia. OBJECTIVES Robotic partial nephrectomy (RPN) has emerged as an attractive minimally invasive nephron‐sparing surgical option. However, on‐going concerns about RPN include: (i) prolonged ischaemia time with potential implications on renal functional outcomes, and (ii) questions about the ability of RPN to address technically challenging hilar tumours. Herein, we detail the technique and present initial perioperative outcomes of our novel technique of zero‐ischaemia RPN for complex hilar tumours. PATIENTS AND METHODS Since May 2010, >100 patients underwent minimally invasive zero‐ischaemia PN. Of these, 21 had procedure done robotically. Of these, seven patients had hilar tumours. RPN was offered to all patients irrespective of tumour or reno‐vascular anatomy, contralateral kidney characteristics or renal function. Data were prospectively collected and recorded in an Institutional Review Board‐approved database. We detail our zero‐ischaemia RPN technique and present early perioperative outcomes. RESULTS Zero‐ischaemia RPN was successful in all cases without any hilar clamping. The median (range) tumour size was 4.1 (2.6–6.4) cm and the median RENAL score was 10 (8–10). The warm ischaemia time was zero in all cases. The median (range) operative time was 222 (150–330) min, estimated blood loss was 150 (100–500) mL, and the percentage kidney spared was 75 (50–90)%. The median hospital stay was 4 (3–6) days. There were no intraoperative complications; two patients had postoperative complications (Clavien grade I and II). No patient had a postoperative haemorrhage, urological/renal complication or lost a kidney. All tumour specimens had negative surgical margins on pathology. The median absolute decrease in serum creatinine and estimated glomerular filtration rate at discharge was 0 (0.2–0.7) mg/dL ( P = 0.4) and 5 (−16 to 29) mL/min per 1.73 m 2 ( P = 0.8), respectively. CONCLUSION Zero‐ischaemia RPN for hilar tumours is safe and feasible and to our knowledge the first report in the literature. Elimination of warm ischaemia may optimally preserve renal function. Prospective randomized studies are needed to confirm any renal functional advantages of clamp‐free RPN. Global renal ischaemia appears to be unnecessary during RPN for hilar tumours.