ICG marked Off-C Robotic Partial Nephrectomy for endophytic renal tumors: proof of concept and initial series
Partial nephrectomy for endophytic renal tumors is a challenging surgical procedure. The use of intraoperative ultrasound allows the surgeon to localize the tumor and to score the resection margins, without any data about the deep part of resection. We describe a novel technique to mark endophytic renal tumors with transarterial superselective delivery of indocyanine green (ICG)-lipiodol mixture, in patients selected for purely off clamp (OC) robotic partial nephrectomy (RPN).
Materials and Methods
Between September 2017 and October 2017, 10 consecutive patients with predominantly or totally endophytic renal masses underwent superselective transarterial tumor ICG marking and bland embolization immediately before OC-RPN. Preoperative transarterial bland embolization was performed with superselective delivery of lipiodol-ICG mixture (1 to 2 by volume, mixing 1.5 millilitres of ICG with 3 millilitres of lipiodol) into tertiary order arteries feeding the tumor. Purely OC-RPN was performed. Near infrared fluorescence imaging was used to early identify the tumor (Fig. 1A), to score resection margins (Fig. 1B) and to obtain an image guided control of resection margins (Fig. 1C).Baseline, clinical, perioperative and pathologic data were reported.
Median tumor size was 3 cm (IQR 2.3-3.8). Median PADUA nephrometry score was 10 (IQR 9-11) Median operative time was 75 minutes (IQR 65-85), median estimated blood loss was 250 mL (IQR 200-350). Bland embolization was uneventful in all patients. Hilar clamp was not necessary in any case, as well as no conversion to radical nephectomy was needed. Perioperative course was uneventful for all patients and median hospital stay was 3 days (IQR 2-3). At discharge, median Hgb and percent eGFR drop down were -3.3 g/dL (IQR 2.1-3.3) and -11% (IQR 10-20), respectively. Surgical margins were negative in all cases. Eight (80%) patients had renal cell carcinoma histology at final pathology.
We previously reported our experience with off-clamp partial nephrectomy with preoperative superselected transarterial embolization . We describe a novel technique to simplify challenging RPNs based on ICG-lipiodol tumor marking with preoperative superselective bland embolization. Key benefits of this technique include a quick identification of the mass, avoiding any use of intraoperative ultrasound imaging, and a real time control of resection margins thanks to an improved visualization of tumor.
The technique we described may simplify challenging RPNs, thanks to a quick identification of the mass, avoiding any use of intraoperative ultrasound imaging, and a real time control of resection margins thanks to an improved visualization of tumor.
1. Zero ischemia laparoscopic partial nephrectomy after superselective transarterial tumor embolization for tumors with moderate nephrometry score: long-term results of a single-center experience.
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