title: Zero ischemia anatomical partial nephrectomy: a novel approach.
abstract: OBJECTIVE
  We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy.
  
  
  METHODS
  Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database.
  
  
  RESULTS
  Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney.
  
  
  CONCLUSIONS
  The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.
authors.affiliation: Center for Advanced Robotic & Laparoscopic Surgery, USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, USA. gillindy@gmail.com
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Mukul B
authors.initials: MB
authors.lastname: Patil
authors.forename: Andre Luis de Castro
authors.initials: AL
authors.lastname: Abreu
authors.forename: Casey
authors.initials: C
authors.lastname: Ng
authors.forename: Jie
authors.initials: J
authors.lastname: Cai
authors.forename: Andre
authors.initials: A
authors.lastname: Berger
authors.forename: Manuel S
authors.initials: MS
authors.lastname: Eisenberg
authors.forename: Masahiko
authors.initials: M
authors.lastname: Nakamoto
authors.forename: Osamu
authors.initials: O
authors.lastname: Ukimura
authors.forename: Alvin C
authors.initials: AC
authors.lastname: Goh
authors.forename: Duraiyah
authors.initials: D
authors.lastname: Thangathurai
authors.forename: Monish
authors.initials: M
authors.lastname: Aron
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D004867:Equipment Design; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D021621:Imaging, Three-Dimensional; D007511:Ischemia / Q000517:prevention & control*; D007668:Kidney / Q000098:blood supply* / Q000000981:diagnostic imaging; D007680:Kidney Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D010535:Laparoscopy; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D042282:Microdissection; D008875:Middle Aged; D009392:Nephrectomy / Q000295:instrumentation / Q000379:methods*; D011183:Postoperative Complications; D011446:Prospective Studies; D011877:Radionuclide Imaging; D012371:Robotics; D018709:Statistics, Nonparametric; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome