CLAMPLESS LAPAROSCOPIC PARTIAL NEPHRECTOMY: PRELIMINARY EXPERIENCE

Roberto Sanseverino1, Olivier Intilla1, Giovanni Molisso1, Tommaso Realfonso1, Maria Addesso2, Giorgio Napodano1
  • 1 Ospedale Umberto I - ASL Salerno, U.O.C. Urologia (Nocera Inferiore)
  • 2 Ospedale Umberto I - ASL Salerno, U.O.C. Anatomia Patologica (Nocera Inferiore)

Objective

Nephron sparing surgery is now reference standard for many T1 renal tumors. Although hilar clamping creates bloodless operative field, it necessarily imposes kidney ischemic injury. ”Zero ischemia” partial nephrectomy allows to eliminate ischemia during nephron sparing surgery.We report our preliminary experience of “zero ischemia” laparoscopic partial nephrectomy realized by controlled hypotension.

Materials and Methods

Patients with a single, clinical T1 tumor were candidates for “zero ischemia” laparoscopic partial nephrectomy. High-risk patients with severe, preexisting, cardiopulmonary, cerebrovascular, or hepatorenal dysfunction were not eligible. The preoperative work-up comprised medical history, physical examination, routine laboratory tests and CT scan or MRI.A transperitoneal approach was performed in all patients; four or five laparoscopic ports are inserted. The hilar vessels are prepared in event that bulldog clamping may subsequently be needed.Intraoperative monitoring includes electrocardiogram, central venous pressure (CVP), electroencephalographic bispectral (BIS) index (BIS monitor™), NICOM (non invasive cardiac output monitoring), urinary Foley catheter. A controlled hypotension, to carefully lower the mean arterial pressure (MAP) while maintaining excellent systemic perfusion, is maintened at approximately 60 mmHg. To induce hypotension, the doses of inhalational isoflurane is increased. The renal lesion is excised using cold endoshears. Upon completion of tumor excision, blood pressure is restored to preoperative levels. Parenchyma is repaired withVicryl™ sutures arrested with absorbable clips and Hem-O-lok™. Biologic hemostatic agents and Surgicel™ are applied to the resection bed.

Results

85 patients affected by renal tumor underwent zero ischemia LPN. Mean age and mean BMI were 58.2 (±12.2) years and 27.8 (±5.3). ASA score was 1, 2 and 3 in 5, 47 and 48 patients, respectively. Charlson comorbidity index was 3.2±1.6. Renal score was low (4-6) in 20,5%, moderate (7-9) in 71,8% and high (10-12) in 7,75 or the patients.
Mean tumor size was 42.9 mm (±15.4). Operative time, blood loss, ∆Hb were 148.7 min (±54.9), 374.2 ml (±365.5), 2.1 gr/dl (±1.2), respectively. Hilar vessels were isolated in 44.2%. In all cases the procedure was performed without clamping. Resection, first and scond suture times were 7.9 (±3.9), 9.6 (±6.4) and 7.3 (±3.2) minutes, respectively. Hospital stay was 6.5 (±5.6) days. Postoperative complications were: 5 fever (Clavien I), 1 fever (Clavien II), 3 urine leakage managed conservatively (Clavien IIIa). Histological evaluation revealed benign lesion in 4 pts, Oncocytoma in 10 pts, AML in 4 pts, complex cyst in 1 pts, Papillary RCC in 14 pts, Cromophobe RCC in 5 pts, clear cell RCC in 47 pts [pT1a (31 pts), pT1b (25 pts), T2 (2 pts), T3a (7 pts)]. Preoperative and postoperative serum Creatinine was 0.8 ±0.24 and 0.9 ±0.22, respectively (Δ0.05±0.08; Δ% -6.2); Preoperative and postoperative GFR was 96.43 ±33.03 and 88.03 ±26.35, respectively (Δ-8.41 ±12.97 Δ% -8.7).

Conclusion

Zero ischemia LPN represents a safe and reproducible technique that allow to sparing renal parenchyma and preserve renal function. However long-term results are needed.

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