A Case of Cerebral Air Embolization During Robot‐Assisted Partial Nephrectomy via a Retroperitoneal Approach for the Patient With Renal Cell Carcinoma

Stroke caused by cerebral air embolism during endoscopy

Trans-retro partial nephrectomy: A novel approach for posterior kidney tumors

Background: Retroperitoneal approach and segmental renal artery clamping in partial nephrectomy are techniques that facilitate postoperative recovery and renal function preservation. This study aimed to compare the renal function preservation and perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) with these techniques. Materials and Methods: Clinical parameters of 43 patients who had undergone retroperitoneal RAPN from March 2017 to December 2019 were retrospectively collected and compared with those of 52 patients who had undergone retroperitoneal LPN at the same period in our institution. Differences in operating time, warm ischemia time, estimated blood loss, complications, postoperative hospital stay, as well as renal function loss were compared between the two groups. Results: Background characteristics between RAPN and LPN groups such as age, gender, BMI, and tumor characteristics were comparable. All RAPNs and LPNs were successfully completed without conversion to open surgery or nephrectomy. No significant difference in operating time, estimated blood loss, complications, and postoperative hospital stay was observed between RAPN and LPN groups. The warm ischemia time in RAPN group was slightly shorter than that of LPN groups (P = .054). Compared with the LPN group, the RAPN group was significantly associated with less glomerular filtration rate reduction and renal volume loss rate (P = .042 and P = .013, respectively). Conclusions: The perioperative outcomes were comparable between the two groups. However, compared with LPN, RAPN had superiority in preserving renal function in our series.

The purpose of this study was to compare perioperative outcomes of transperitoneal (TP) and retroperitoneal (RP) robot-assisted partial nephrectomy (RPN) by matched analysis using nephrometry systems. A total of 107 patients who underwent RPN by a single surgeon from December 2008 to June 2012 were analyzed; 57 patients underwent TP RPN and 50 patients underwent RP RPN. Baseline demographic characteristics, perioperative outcomes and changes in renal function were collected by retrospective review of medical records. Matched-pair comparisons were done using RENAL score and C-index. No significant difference was observed between TP and RP RPN in patient age, body mass index, gender, laterality, clinical stage, tumor size, RENAL score or ASA score. The TP RPN had more cystic renal masses (TP vs. RP = 33 vs. 12 %, p = 0.012) and RP RPN had shorter median operation times (150 vs. 120 min, p = 0.015) and shorter mean warm ischemic times (26.2 vs. 22.6 min, p = 0.040) than TP RPN. In the matched-pair analysis, RP RPN showed shorter operation times with similar warm ischemic times. Estimated blood loss and visual analog pain scales showed no significant differences between groups. A total of 12 (11.4 %) postoperative complications occurred, all Clavien class I or II with no significant difference in incidence. Retroperitoneal robot-assisted partial nephrectomy showed shorter operation time and generally equivalent perioperative results to TP RPN. RP RPN is a viable treatment option for treating posterior or lateral renal masses.

Stroke caused by cerebral air embolism during endoscopy

To compare the effects of transperitoneal and retroperitoneal approaches for robotic assisted partial nephrectomy (RAPN) in patients with renal cell carcinoma (RCC). We conducted a retrospective cohort study on RAPN at Affiliated Hospital of Jiangsu University. Between September 2020 and February 2024, the included patients underwent either transperitoneal approach or retroperitoneal approach. Perioperative status, stress response, quality of life, and incidence of complications were compared between the groups. A total of 105 patients were included in this analysis, with 54 patients in the Retroperitoneal group, and 51 patients in the Transperitoneal group. The retroperitoneal approach was associated with significantly better perioperative indicators compared to the transperitoneal method (P<0.05). After the surgery, serum levels of interleukin-6 (IL-6), C-reactive protein (CRP), white blood cell count (WBC), and cortisol (Cor) in the Retroperitoneal group were lower than in the Transperitoneal group (P<0.05). The quality-of-life scores of patients in the Retroperitoneal group were higher (P<0.05), but no statistically significant difference in the incidence of complications between the groups (P>0.05). Compared with the transperitoneal approach, the retroperitoneal method of RAPN is equally safe and is associated with improved perioperative status, lower stress response, and better quality of life for RCC patients.

MP68-07 A COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACH IN PATIENTS UNDERGOING SINGLE-PORT ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: A REPORT FROM THE SINGLE PORT ADVANCED RESEARCH CONSORTIUM (SPARC)

Complications After Robotic Partial Nephrectomy at Centers of Excellence: Multi-Institutional Analysis of 450 Cases

Although very comprehensive, the AAGBI safe vascular access guideline fails to mention the important role of hyperbaric oxygen therapy (HBOT) in the management of air embolism complicating vascular access 1. Depending on the speed and quantity of air/gas entrainment, cardiac arrest may be irreversible. Some patients are resuscitated successfully; others have insidious onset, presenting with air in the coronary or cerebral circulation. The latter present with varied neurological signs, but a ‘peri-procedural stroke’ should trigger suspicion of cerebral air embolism, a life-threatening emergency. Although there are case reports of these being aspirated percutaneously, the most effective treatment is urgent HBOT 2-4. The outcome is dependent on HBOT within 6–8 h, akin to early thrombolysis in thromboembolic stroke. Hyperbaric oxygen therapy beyond this ideal window should still be considered and discussed with experts in the field. Good outcomes from delayed HBOT may be more likely related to retrograde cerebral venous air embolism rather than cerebral arterial air embolism. Peripheral venous lines have been described many times as a source of cerebral gas embolism, and the absence of a central line should not exclude the diagnosis. The pathophysiology of gas bubbles in the cerebral vascular system and the mechanism of HBOT has been clearly described 5. The diagnosis may be difficult, and a high index of suspicion is required in case of a peri-procedural neurological event, including any form of vascular procedure. Sometimes the diagnosis is inevitably associated with delays, but once the diagnosis is made, every minute counts. For that reason, clear guidance is essential. The quoted incidence of 0.8% of all air embolism events translates into several dozen cases per year of significant cerebral gas embolism, which currently may be missed in the UK 1. The incidence may be higher 2-4. Vascular-related air embolism has recently been removed from the ‘Never Event’ list in the UK and it will be interesting to see if the rate of reporting will change. The British Hyperbaric Association has guidance on their website about how to access emergency HBOT in a suitable Category 1 unit (able to deal with critically ill patients) 6.

IntroductionHorseshoe kidney is a renal fusion anomaly often associated with ectopia, malformation, and vascular changes. Robot‐assisted partial nephrectomy is selected for patients with T1a renal cell carcinoma; however, there are few reports of renal cell carcinoma in horseshoe kidney. We present a case of robot‐assisted partial nephrectomy via a retroperitoneal approach in a patient with horseshoe kidney with a brief literature review.Case presentationAn 84‐year‐old woman presented with a 2‐cm mass in horseshoe kidney. She underwent robot‐assisted laparoscopic partial nephrectomy via a retroperitoneal approach.ConclusionThe use of robot‐assisted laparoscopic partial nephrectomy in patients with horseshoe kidney is very rare, and only four cases have been reported. Because of the unique anatomical structure, surgeons need to consider surgical strategy more carefully, considering tumor location, vascular anatomy, and past history of abdominal surgery.

To compare intraoperative blood loss in robot-assisted partial nephrectomy (RAPN) between the right and left sides. The data of patients who underwent RAPN at a single institution between 2013 and 2021 were retrospectively analyzed. Using propensity score matching, we compared estimated blood loss (EBL) between right- and left-sided tumors. This study included 1006 patients who underwent transperitoneal RAPN (N=726) and retroperitoneal RAPN (N=280). Through matching, 303 patients were selected for each group. The mean tumor size was 3.1 ± 1.4cm. The RENAL score was 4-6 in 270 (44.5%), 7-9 in 263 (43.3%), and 10-11 in 73 (12.0%) cases. The EBL on the right side was significantly higher than on the left side (102 vs 70 mL, P=.02). The most experienced surgeon showed significant differences in EBL (116 vs 73 mL, P=.024) and blood transfusion rate (2.5 vs 0%, P=0.025) between the right and left sides. In the retroperitoneal RAPN, 104 patients were selected in each group through matching. The EBL was significantly higher on the right side than on the left side (50 vs 24 mL, P=0.02). Operative time was longer on the right side than on the left side (120 vs 109 min, P=.05). Right-sided tumors had a significantly larger EBL than left-sided tumors in RAPN. The difference was evident in the most experienced surgeon who performed RAPN for larger and complicated cases. This information may help surgeons decide whether to clamp the renal artery and vein during tumor resection in large and complicated right-sided tumors.

MP47-20 PROGNOSTIC FACTORS FOR RECURRENCE AFTER ROBOT-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY: REAL-WORLD DATA FROM JAPANESE SINGLE HIGH-VOLUME CENTER

Objective To explore the clinical efficacy and safety of off-clamping in robotic-assisted partial nephrectomy (RAPN) for the treatment of renal tumors. Methods From January 2015 to March 2017, the data of 48 patients who underwent off-clamping RAPN were reviewed retrospectively. There were 31 males and 17 females, and the mean age was 57 years (range: 23-84 years). The mean tumor size was 3.1 cm (range: 1.2-6.4 cm), with the upper, middle, and lower polar tumors account for 35.4%, 27.1%, and 37.5%, respectively. The clinical tumor stage was T1N0M0 in all 48 cases, according to the AJCC tumor staging system for renal cancer. Results RAPNs were performed successfully in all 48 cases, without conversion to open surgery. In those patients, the application of off-clamping in robotic-assisted partial nephrectomy was performed in 44 cases. The renal artery and vein was exposed, dissected, isolated and then clamped in 4 cases due to bleeding. The mean surgical time was 85 min (range: 75-185 min). The mean estimated blood loss was 134 ml (range: 60-270 ml), and no blood transfusion was needed. The wound surface was closed using interrupted suture with Hem-o-lok clips securing each needle point. The mean time for renorrhaphy was 22 min (rang: 11-31 min). No intraoperative severe complications such as vascular injury, trauma of abdominal organ occurred. There were 5 complications, including 2 cases of hematuria, 2 cases of delayed healing of incision, and 1 case of pneumohypoderma. The pathological diagnosis included 40 cases of renal clear cell carcinoma, 3 cases of papillary renal cell carcinoma, and 5 cases of angiomyolipomas. No tumor recurrence or distant metastasis was observed during the average follow-up of 17 months (range 3-27 months). Conclusions Off-clamping RAPN is safe and feasible approach to excise certain kidney tumors. It carries the benefits of less complication, quick recovery, and less ischemia reperfusion renal injury. Off-clamping RAPN would be suitable for those patients with solitary kidneys, renal insufficiency, and bilateral tumors. Key words: Robotic surgery; Partial nephrectomy; Off-clamping; Renal tumor

Solid Renal Masses in Transplanted Allograft Kidneys: A Closer Look at the Epidemiology and Management.

Simple Enucleation is Equivalent to Traditional Partial Nephrectomy for Renal Cell Carcinoma: Results of a Nonrandomized, Retrospective, Comparative Study