"Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique.
BACKGROUND
Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative.


OBJECTIVE
Describe a novel technique of "zero ischemia" laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy.


METHODS
Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n=12), RAPN (n=3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n=9; 60%), hilar (n=1), in solitary kidney (n=1), in patients with chronic kidney disease grade 3 or greater (n=3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis.


METHODS
Intraoperative and early postoperative data were collected prospectively.


CONCLUSIONS
All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1-4); operative time was 3 h (range: 1.3-6); blood loss was 150 ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65 mm Hg (median: 60), typically for 1-5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n=5) included urine retention (n=1), septicemia from presumed prostatitis (n=1), atrial fibrillation (n=1), urine leak (n=2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively.


CONCLUSIONS
A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.
Center for Advanced Robotic & Laparoscopic Surgery, USC Institute of Urology, Division of Nephrology and Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. gillindy@gmail.com
Inderbir S
IS
Gill
Manuel S
MS
Eisenberg
Monish
M
Aron
Andre
A
Berger
Osamu
O
Ukimura
Mukul B
MB
Patil
Vito
V
Campese
Duraiyah
D
Thangathurai
Mihir M
MM
Desai
D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure; D050377:Cold Ischemia; D003250:Constriction; D003404:Creatinine / Q000097:blood; D005919:Glomerular Filtration Rate; D006801:Humans; D007680:Kidney Neoplasms / Q000097:blood / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D010535:Laparoscopy; D015141:Los Angeles; D008297:Male; D042282:Microdissection; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D011446:Prospective Studies; D012077:Renal Artery / Q000503:physiopathology / Q000601:surgery; D012082:Renal Veins / Q000503:physiopathology / Q000601:surgery; D012371:Robotics; D025321:Surgery, Computer-Assisted; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color; D014665:Vasodilator Agents / Q000008:administration & dosage; D052096:Warm Ischemia
D015415:Biomarkers; D014665:Vasodilator Agents; D003404:Creatinine