Selective versus nonselective arterial clamping during laparoscopic partial nephrectomy: impact upon renal function in the setting of a solitary kidney in a porcine model.
BACKGROUND
Laparoscopic partial nephrectomy has emerged as a standard of care for small renal masses. Nevertheless, there remains concern over the potential for irreversible insult to the kidney as a result of exposure to warm ischemia. We aim to investigate the utility of selective segmental arterial clamping as a means to reduce the potential for ischemic damage to a solitary kidney during laparoscopic partial nephrectomy utilizing a porcine model.


METHODS
A total of 20 domestic swine were randomized into four equal groups. Each subject underwent laparoscopic radical nephrectomy to create the condition of a solitary kidney. On the contralateral side, a laparoscopic lower pole partial nephrectomy was performed, employing either selective or nonselective vascular clamping for either 60 or 90 minutes. Postoperatively, clinical status and serial serum studies were closely monitored for 1 week.


RESULTS
There were no intraoperative complications. The 90-minute nonselective clamping produced devastating effects, resulting in rapid deterioration into florid renal failure within 72 hours. The 60-minute nonselective clamping group experienced modest but significant rises in both blood urea nitrogen and creatinine. Both 60- and 90-minute selective clamping groups performed well, with no significant rises in creatinine over a 7-day period, and no instances of renal failure.


CONCLUSIONS
Selective arterial clamping is a safe and feasible means of vascular control during laparoscopic partial nephrectomy. In the porcine model, selective clamping appears to improve functional outcomes during prolonged periods of warm ischemic insult. Prospective evaluation of the technique in humans is necessary to determine if selective arterial control confers long-term functional benefits in patients with limited renal reserve.
Benway
Brian M
BM
Division of Urologic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
Baca
Geneva
G
Bhayani
Sam B
SB
Das
Nitin A
NA
Katz
Matthew D
MD
Diaz
Dilmer L
DL
Maxwell
Keegan L
KL
Badwan
Khalid H
KH
Talcott
Michael R
MR
Liapis
Helen
H
Cabello
Jose M
JM
Venkatesh
Ramakrishna
R
Figenshau
Robert S
RS
D000818:Animals; D001806:Blood Urea Nitrogen; D003250:Constriction; D003404:Creatinine / Q000097:blood; D004195:Disease Models, Animal; D007674:Kidney Diseases / Q000473:pathology / Q000503:physiopathology*; D007677:Kidney Function Tests; D010535:Laparoscopy; D009392:Nephrectomy / Q000379:methods*; D011182:Postoperative Care; D012077:Renal Artery / Q000473:pathology* / Q000503:physiopathology*; D034421:Sus scrofa; D013997:Time Factors
D003404:Creatinine