Over 100 cases of zero-ischemia robotic/laparoscopic partial nephrectomy: Is global renal ischemia necessary?

Abstract

e15060 Background: We report peri-operative and short-term outcomes of a novel technique of zero-ischemia robotic and laparoscopic partial nephrectomy (PN) for renal masses. Methods: From March 2010 to July 2011, 100 zero-ischemia robotic (n=40) and laparoscopic (n=60) PN were performed at our institution. The technique consists of performing micro-dissection of tertiary or higher-order renal arterial branches to super-selectively devascularize the tumor and surrounding parenchyma. Blood flow continues uninterrupted to the remainder of the kidney. As such, PN is performed without hilar cross-clamping. The procedure was offered to all-comers regardless of the tumor complexity or renovascular anatomy. Results: Median patient age was 59 years, tumor size was 3cm (0.9-13.6), baseline serum creatinine (SCr) was 1 mg/dl (0.5-2.6), and estimated glomerular filtration rate (eGFR) was 73 ml/min per 1.73m2 (24-149). 9 patients had a solitary kidney and 8 patients had multiple ipsilateral tumors. Overall, 70% of tumors were complex: central (43%), completely intra-renal (23%), cT1b >4cm (21%), and hilar (19%). Median (range) RENAL, PADUA and C-Index scores were 8 (4-11), 9 (6-13), 2.2 (0.5 c 13.2), respectively. Warm ischemia time was zero, median operative time was 275 min (126-534), estimated blood loss was 200cc, percent of kidney excised was 20 (5-70) and hospital stay was 4 days (2-20). There were 13 complications in 12 patients, with major complications, Clavien grade ≥3, in 4 patients. Histology confirmed malignancy in 80% of tumors. All surgical margins were negative for cancer. There were no significant difference for median percent change in SCr, 0 mg/dl (-31 to 215), and eGFR, -1 (-74 to 53), at discharge. In 65 patients with more than 2 months (median 219 days) follow up data available, median percent change in SCr and eGFR were 18 (-31 to 154), p<.001 and -18 (-66 t0 53), p<.001, respectively. 1 patient developed pulmonary metastases at 1 year follow up. Conclusions: Zero-ischemia robotic/laparoscopic PN without hilar clamping is feasible and safe. It could be performed even in the setting of complex tumors and various vascular anatomy scenarios. Eliminating global renal ischemia now appears achievable.