title: Zero-ischaemia robotic partial nephrectomy (RPN) for hilar tumours.
abstract: OBJECTIVE
  • 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.
  
  
  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.
  
  
  CONCLUSIONS
  • 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.
authors.affiliation: University of Southern California Institute of Urology, Center for Advanced Robotic and Laparoscopic Surgery, Keck School of Medicine, USC, Los Angeles, CA, USA.
authors.forename: André L C
authors.initials: AL
authors.lastname: Abreu
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003250:Constriction; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D007511:Ischemia / Q000517:prevention & control*; D007668:Kidney / Q000098:blood supply*; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D042282:Microdissection; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D009392:Nephrectomy / Q000379:methods*; D011446:Prospective Studies; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000379:methods; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color