Clampless Partial Nephrectomy Research Articles

Radiofrequency-assisted, laparoscopic, clampless partial nephrectomy in patients with low-complexity small renal tumors: A retrospective cohort study.

This single-center, retrospective study was performed to investigate the safety and efficacy of radiofrequency-assisted (RF), laparoscopic partial nephrectomy (PN) with zero ischemia in patients with low-complexity small renal tumors. Patients with small renal masses (SRMs) who underwent laparoscopic, clampless laparoscopic partial nephrectomy - radiofrequency assisted (LPN-RFA) between January 2016 and June 2020 were studied. Demographics, clinical and pathological characteristics, recurrence-free survival, and overall survival were recorded. Fifty-two SRMs were excised from corresponding patients using RFA-LPN. The median tumor size was 2.5 cm and all specimens involved low-complexity masses according to the renal nephrometry score. No conversions to radical nephrectomy were recorded. Postoperatively, there were one patient with fever, one with hematuria, and two with urinary leakage treated endoscopically. The majority of tumors (48/52, 86.2%) were clear-cell carcinomas. According to the glomerular filtration rate postoperatively and 12 months' posttreatment, adequate renal function was preserved in all patients. There were no positive surgical margins identified postoperatively and no recurrences during a median follow-up 24 months. All patients were alive at the last follow-up. This study suggests that RFA laparoscopic clampless PN represents an effective method for managing patients with low-complexity SRMs. It offers adequate intraoperative safety and excellent mid-term oncological control and functional preservation.

A0338 - Clamp-less partial nephrectomy: A propensity score-matched analysis comparing robot-assisted with open approach

A0338 - Clamp-less partial nephrectomy: A propensity score-matched analysis comparing robot-assisted with open approach

Clampless and sutureless laparoscopic partial nephrectomy using monopolar coagulation with or without N-butyl-2-cyanoacrylate

ObjectiveTo describe a novel technique for clampless and sutureless laparoscopic partial nephrectomy (LPN) using monopolar coagulation with or without N-butyl-2-cyanoacrylate (NBCA).MethodsFrom February 2015 to October 2018, we performed clampless and sutureless LPN using monopolar coagulation with or without NBCA on 142 patients. The tumors were resected with cold scissor. The tumor beds were repeatedly coagulated with a monopolar hook in spray and fulgurate modes. NBCA was sprayed when bleeding was observed after coagulation in 98 patients. We compared outcomes in the NBCA and non-NBCA groups.ResultsMean patient age was 55 years (range 20–86). Mean tumor size was 3.2 cm (range 1.0–10.6). Mean RENAL nephrometry score was 5 (range 4–8). Mean operative time was 120 min (range 40–200). Mean estimated blood loss was 100 ml (range 10–500). Mean eGFR changes were 2.3 ml/min. Two patients had positive surgical margins. Three patients received blood transfusions. No patients had urine leakage. Patients receiving NBCA had larger tumors (3.0 vs 2.0 cm, p < 0.001), higher RENAL nephrometry scores (5.59 vs 4.47, p = 0.004), and higher E item scores (p = 0.009).ConclusionsUse of monopolar coagulation with NBCA in clampless and sutureless LPN for renal tumors with low RENAL nephrometry scores is safe and effective. For patients with exophytic renal tumors less than 2 cm, NBCA is not necessary.

Robot-assisted Partial Nephrectomy and Bilateral Pyelolithotomy in Ectopic Pelvic Kidneys

ObjectiveTo show how to perform a robot-assisted partial nephrectomy and bilateral pyelolithotomy in ectopic pelvic kidneys. This is a congenital abnormality of position and rotation1 frequently associated with urolithiasis.2 Renal cell carcinoma is a very rare event in pelvic kidneys.3,4 These 2 findings in the same patient could be a surgical challenge and whenever possible a “one stage” treatment is preferred. Materials and MethodsA 44-year-old male with bilateral pelvic kidneys admitted because of left back pain. Abdominal CT scan showed a 17 mm stone in the left renal pelvis, a 12 mm stones in the right pelvis and a 34 × 27 mm right lower pole renal mass. A robotic surgery was indicated. Patient was placed in Trendelenburg position with ports configuration as for transperitoneal radical prostatectomy. The right kidney was firstly approached: after isolation of the ureter and suspension of the renal artery, a clampless partial nephrectomy was performed; then through a longitudinal pyelotomy the stone was extracted. To minimize the opening of the posterior peritoneum covering the left kidney, the site of the stone was identified by intraoperative ultrasound; then, through a longitudinal pyelotomy the stone was extracted. Given the watertight sutures and the lack of ureteral obstructions no pigtails ureteral catheters were inserted. A Jackson-Pratt drainage was placed through the inferior port. ResultsConsolle time was 190 minutes. Estimated Blood Loss (EBL) was 50 ml. No complications were reported. The drain was removed on the second postoperative day, assessed that creatinine dosage was equal to serum. The length of stay was 4 days. Histopathology showed a pT1a G2 clear cell renal cell carcinoma with negative surgical margins, while stones analysis was calcium oxalate. ConclusionWith the availability of robotic technology, the indications for minimally invasive surgery may be safely expanded to include concomitant morbidities in uncommon presentations.

Acute kidney injury and intermediate-term renal function after clampless partial nephrectomy.

To evaluate the incidence and predictors of acute kidney injury after clampless partial nephrectomy, and its impact on intermediate-term renal function. The incidence and severity of acute kidney injury were assessed for 262 patients undergoing clampless partial nephrectomy between 2010 and 2015. The association between perioperative covariates and acute kidney injury was evaluated using multivariate logistic regression analysis. An annual change in estimated glomerular filtration rate from 1year after surgery was calculated according to the presence or absence of acute kidney injury. An impact of acute kidney injury on postoperative renal impairment, defined as a ≥25% estimated glomerular filtration rate decrease, was evaluated. Overall, 21 (8.0%) patients experienced grade1 acute kidney injury after clampless partial nephrectomy, and grade≥2 acute kidney injury was not observed. High tumor complexity was the only independent predictor of acute kidney injury. Estimated glomerular filtration rate in patients with acute kidney injury improved within 1year, and annual estimated glomerular filtration rate changes were similar among patients with or without acute kidney injury. Ultimately, 13 (5.0%) patients showed postoperative renal impairment during the median follow-up period of 37months. Advanced age and diabetes mellitus were independent risk factors for renal impairment, but acute kidney injury was not. The incidence and severity of acute kidney injury after clampless partial nephrectomy are low. Low-grade acute kidney injury after clampless partial nephrectomy does not seem to affect intermediate-term renal function.

MP42-05 ACUTE KIDNEY INJURY AND INTERMEDIATE-TERM RENAL FUNCTION AFTER CLAMPLESS PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy IV1 Apr 2018MP42-05 ACUTE KIDNEY INJURY AND INTERMEDIATE-TERM RENAL FUNCTION AFTER CLAMPLESS PARTIAL NEPHRECTOMY Minato Yokoyama, Naoko Kawamura, Sho Uehara, Yosuke Yasuda, Toshiki Kijima, Soichiro Yoshida, Junichiro Ishioka, Yoh Matsuoka, Kazutaka Saito, Kazunori Kihara, and Yasuhisa Fujii Minato YokoyamaMinato Yokoyama More articles by this author , Naoko KawamuraNaoko Kawamura More articles by this author , Sho UeharaSho Uehara More articles by this author , Yosuke YasudaYosuke Yasuda More articles by this author , Toshiki KijimaToshiki Kijima More articles by this author , Soichiro YoshidaSoichiro Yoshida More articles by this author , Junichiro IshiokaJunichiro Ishioka More articles by this author , Yoh MatsuokaYoh Matsuoka More articles by this author , Kazutaka SaitoKazutaka Saito More articles by this author , Kazunori KiharaKazunori Kihara More articles by this author , and Yasuhisa FujiiYasuhisa Fujii More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1312AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Some patients experience acute kidney injury (AKI) after partial nephrectomy (PN). The incidence of AKI after PN with hilar clamping has been reported in several studies, and some investigators demonstrated the association of duration or type of ischemia with the incidence of AKI. However, the incidence of AKI after clampless PN and the influence of AKI after PN on longitudinal change in postoperative renal function have not been fully explored. Here, we investigated associations between AKI and intermediate-term renal function after clampless PN. METHODS Between 2010 and 2015, 337 consecutive patients underwent gasless single-port PN and were followed up longer than 1 year. In this surgery, PN was done with an extraperitoneal approach via a single-port without gas insufflation and hilar clamping by using soft coagulation and ultrasonic coagulation system. Of the 337 patients, those with bilateral tumors (n=26), metastases (n=6), solitary kidney (n=4), and those requiring hilar clamping (n=21) were excluded. The association between the occurrence of AKI based on AKI network definition and renal impairment with ≥25% estimated glomerular filtration rate (eGFR) decrease was evaluated using Cox regression model.Then, mean eGFRs of the patients with or without AKI after clampless PN up to 5 years were plotted, and an annual change of eGFR from 1 year after surgery was calculated using linear mixed model. RESULTS Of the 280 patients, Median age, preoperative eGFR, tumor size, operation time, and blood loss was 58 years, 70.6 ml/min/1.73 m2, 2.5 cm, 214 minutes, and 314 ml, respectively. Hypertension, diabetes mellitus, dyslipidemia, and cardiovascular disease coexisted in 38%, 10%, 15%, and 9% of the subjects, respectively. AKI occurred in 21 patients (8%), and all the AKIs observed were grade 1. Median eGFR change at latest follow up (median 36 months) was -9.0%. During the follow up period, no patients required renal replacement therapy.Cox regression analysis showed that AKI was not associated with renal impairment after clampless PN, while advanced age (≥65) and presence of diabetes mellitus were independent risk factors.Annual eGFR changes from 1 year after clampless PN in patients with and without AKI were -0.34 (95% CI: -1.23 ~ 0.54) ml/min/1.73 m2 and -0.36 (-0.72 ~ -0.02) ml/min/1.73 m2, respectively. CONCLUSIONS Renal function was well preserved after clampless PN. The incidence and severity of AKI were low, and AKI after clampless PN was not associated with intermediate-term renal impairment. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e537-e538 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Minato Yokoyama More articles by this author Naoko Kawamura More articles by this author Sho Uehara More articles by this author Yosuke Yasuda More articles by this author Toshiki Kijima More articles by this author Soichiro Yoshida More articles by this author Junichiro Ishioka More articles by this author Yoh Matsuoka More articles by this author Kazutaka Saito More articles by this author Kazunori Kihara More articles by this author Yasuhisa Fujii More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V04-12 ROBOT-ASSISTED PARTIAL NEPHRECTOMY AND BILATERAL PYELOLYTHOTOMY OF ECTOPIC PELVIC KIDNEYS

You have accessJournal of UrologyReconstruction - Upper Urinary Tract1 Apr 2018V04-12 ROBOT-ASSISTED PARTIAL NEPHRECTOMY AND BILATERAL PYELOLYTHOTOMY OF ECTOPIC PELVIC KIDNEYS Carlotta Palumbo, Maria Furlan, Stefania Zamboni, Alessandro Veccia, Angelo Peroni, Alessandro Antonelli, and Claudio Simeone Carlotta PalumboCarlotta Palumbo More articles by this author , Maria FurlanMaria Furlan More articles by this author , Stefania ZamboniStefania Zamboni More articles by this author , Alessandro VecciaAlessandro Veccia More articles by this author , Angelo PeroniAngelo Peroni More articles by this author , Alessandro AntonelliAlessandro Antonelli More articles by this author , and Claudio SimeoneClaudio Simeone More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1029AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Ectopic kidney is congenital abnormality of position and rotation, frequently associated with urolithiasis. In case of large stones, the percutaneous treatment has some specific difficulties related to the anatomy of the kidneys and the pelvis, that viceversa represents the ideal condition for a transperitoneal surgical access.The case here presented, in addition was affected by a bilateral renal lithiasis and an enhancing parenchymal mass of the right lower pole: with the aim to perform a “one-stage” treatment, we planned a robotic surgery. METHODS A 44-years old male admitted because of recurrent left back pain. Past medical history was consistent bilateral pelvic kidneys and ureteral lithiasis spontaneously passed 1 year before.Abdominal contrast enhanced CT scan showed a 17 mm stone in the left renal pelvis, a 12 mm stones in the right pelvis and a 34x27 mm enhancing right lower pole renal mass, with a strict relationship with the prevesical ureter; the angiographic phases revealed a vascular supply to the right kidney from the common iliac artery. A robotic surgery was indicated. Patient was placed in trendelenburg position with Da Vinci® port configuration as for transperitoneal radical prostatectomy, using a 30° lens. The right kidney was firstly approached: after complete isolation of the ureter and its dissection from the tumor, suspension of the renal artery at its emergence from the iliac, a clampless partial nephrectomy was performed; then through a longitudinal pyelotomy was extracted the renal stone. To minimize the opening in the posterior peritoneum and the sigmoid mesentery, covering the left kidney, the site of the pelvis and stone were identified by an intraoperative ultrasound; then, through a longitudinal pyelotomy the stone was extracted. At the end, the peritoneum was sutured. A Jackson-Pratt drainage was place through the inferior robotic port. RESULTS The operative time was 240 minutes, with 190 minutes of console time. Estimated blood loss was 50 mL. No intra or post-operative complications were reported. The drain was removed on the second postoperative day and the length of stay was 4 days. At discharge, the patient had serum creatinine of 0.93 mg/dL and haemoglobin of 12.5 g/dL. Final histopathology showed a pT1a G2 clear cell renal cell carcinoma with a negative surgical margin, while stone analysis showed calcium oxalate stones. CONCLUSIONS With the availability of robotic technology, the indications for minimally invasive surgery may be safely expanded to include concomitant morbidities in uncommon presentations. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e410 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Carlotta Palumbo More articles by this author Maria Furlan More articles by this author Stefania Zamboni More articles by this author Alessandro Veccia More articles by this author Angelo Peroni More articles by this author Alessandro Antonelli More articles by this author Claudio Simeone More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

784 - Acute kidney injury after clampless partial nephrectomy: Incidence, predictors, and its low impact on intermediate-term renal function

784 - Acute kidney injury after clampless partial nephrectomy: Incidence, predictors, and its low impact on intermediate-term renal function

982 Longitudinal preservation of renal function after clamp-less partial nephrectomy: An analysis of patients with chronic kidney disease

982 Longitudinal preservation of renal function after clamp-less partial nephrectomy: An analysis of patients with chronic kidney disease

983 Intraoperative, postoperative and functional outcomes of clampless laparoscopic partial nephrectomy (LPN) for renal tumours with high surgical complexity

983 Intraoperative, postoperative and functional outcomes of clampless laparoscopic partial nephrectomy (LPN) for renal tumours with high surgical complexity

198 Role of urinary neutrophil gelatinase-associated lipocalin in early detection of kidney injury following clampless and clamped laparoscopic partial nephrectomy

198 Role of urinary neutrophil gelatinase-associated lipocalin in early detection of kidney injury following clampless and clamped laparoscopic partial nephrectomy

Integrated image monitoring system using head-mounted display for gasless single-port clampless partial nephrectomy.

A novel head-mounted display (HMD) offers a higher quality of endoscopic imagery in front of the eyes regardless of head position. We present an application of the HMD system as a personal integrated multi-image monitoring system in gasless single-port clampless partial nephrectomy (PN). Our HMD system displayed multiple forms of information as integrated, sharp, high-contrast images both seamlessly and synchronously using a four-split screen. The surgeon wearing an HMD display could continuously and simultaneously monitor the endoscopic, three-dimensional (3D) video and intraoperative ultrasound images. In addition, the operator can rotate the 3D video image using fingertip movements on the finger tracking system. All two clampless partial nephrectomies were safely completed within the operative time, blood loss was within usual limits and there were no complications. The integrated image HMD system might facilitate maneuverability and safety in minimally invasive clampless PN.

94 Kidney injury following clampless and clamped laparoscopic partial nephrectomy: Is an early detection of acute postoperative damage possible? Role of neutrophil gelatinase-associated lipocain

94 Kidney injury following clampless and clamped laparoscopic partial nephrectomy: Is an early detection of acute postoperative damage possible? Role of neutrophil gelatinase-associated lipocain

A Novel 3-Dimensional Image Analysis System for Case-specific Kidney Anatomy and Surgical Simulation to Facilitate Clampless Partial Nephrectomy

To report our initial experience with the novel 3-dimensional (3D) image analysis system Synapse Vincent in clampless partial nephrectomy (PN), describing its advantages with regard to short-term surgical outcomes and its usefulness as an informed consent tool. Twenty-six patients with renal cell carcinoma underwent clampless PN navigated with the aid of case-specific 3D anatomic video images of the kidney, after surgical simulation using the same video system. Baseline characteristics were reviewed, and short-term surgical outcomes were recorded. Of the 26, 6 had imperative indications, and 22 were treated with a minimally invasive approach. Before tumor excision, the renal hilar vessels were meticulously dissected, and definite tumor feeders were selectively ligated. Before patients consented to PN, the surgical procedure and perioperative risks were explained to each patient using case-specific 3D video images; subsequently, surgeons asked patients whether the 3D images had helped them understand PN more clearly than 2D images would have. All operations were successfully completed without clamping, with negative surgical margins. No patients required blood transfusions. During PN, the surgeons confirmed the accuracy of the reconstructed 3D images and surgical simulations in all cases. All patients answered that the 3D images had helped them understand their disease status and surgical risks. This is the first report on the Synapse Vincent 3D image analysis system for kidney surgery. Its 3D images and surgical simulation helped not only surgeons in their performance of clampless PN but also patients in their understanding of the operation.

V21 New 3-dimensional head-mounted display system (RoboSurgeon system) applied to gasless, single-port access, clampless partial nephrectomy

V21 New 3-dimensional head-mounted display system (RoboSurgeon system) applied to gasless, single-port access, clampless partial nephrectomy

204 Kidney injury following clampless laparoscopic partial nephrectomy: Is an early detection of acute postoperative damage possible? A preliminary experience

204 Kidney injury following clampless laparoscopic partial nephrectomy: Is an early detection of acute postoperative damage possible? A preliminary experience

Factors Affecting Renal Function After Open Partial Nephrectomy—A Comparison of Clampless and Clamped Warm Ischemic Technique

To analyze factors impacting postoperative renal function after open partial nephrectomy using both the clampless and clamped warm-ischemic technique. We studied a cohort of patients who underwent clamped partial nephrectomy (n = 164) and clampless partial nephrectomy (n = 64) from March 2002 to March 2009 with ≥ 12-months follow-up. Clamped partial nephrectomy used hilar occlusion before resection. Clampless partial nephrectomy used focal radio frequency coagulation to facilitate hemostasis before resection, nonischemic dissection/resection with hydro-dissection, or sharp resection after local compression. Demographics, tumor characteristics/RENAL nephrometry scores, perioperative variables, and complications were compared between the two methods. Multivariable analysis was performed to identify factors predicting de novo estimated glomerular filtration rate <60. Patient characteristics were similar between groups. Mean RENAL score was greater in clamped (6.9) vs clampless (6.4, P = .026); complications (P = .430) and urine leaks (clampless partial nephrectomy 3.1% vs clamped-PN 7.3%, P = .360) were similar. Mean warm ischemia time (min) was 24.5 for clamped partial nephrectomy. De novo estimated glomerular filtration rate <60(%) at last follow up was 13.5 (clamped) vs 3.1 (clampless) (P = .071). Multivariable analysis of the entire cohort revealed increasing body mass index (OR 1.1, P = .042) and RENAL score (OR 1.71, P = .002) as being independently associated with development of postoperative de novo estimated glomerular filtration rate <60. Multivariable analysis of the clamped subgroup demonstrated increasing body mass index (OR 1.12, P = .028), RENAL score (OR 1.56, P = .010), and ischemia time (OR 1.15, P = .042) as independent factors associated with de novo estimated glomerular filtration rate <60. Body mass index and RENAL score were factors predictive of development of de novo estimated glomerular filtration rate <60 after partial nephrectomy, with increasing warm ischemia time also being predictive in clamped partial nephrectomy patients. Further investigation and long-term functional data are requisite.

143 Feasibility of gasless single-port clampless partial nephrectomy for peripheral renal tumor: An experience of 118 consecutive cases

143 Feasibility of gasless single-port clampless partial nephrectomy for peripheral renal tumor: An experience of 118 consecutive cases

Radiofrequency Ablation–Assisted Robotic Laparoscopic Partial Nephrectomy Without Renal Hilar Vessel Clamping Versus Laparoscopic Partial Nephrectomy: A Comparison of Perioperative Outcomes

Radiofrequency ablation (RFA)-assisted laparoscopic partial nephrectomy (LPN) may allow for improved hemostasis without need for renal hilar vessel clamping and elimination of warm ischemia to the kidney. We compare outcomes in patients undergoing radiofrequency ablation-assisted robotic clampless partial nephrectomy (RF-RCPN) and LPN. Thirty-six patients and 42 patients underwent LPN and RF-RCPN, respectively. In the RF-RCPN group, the Habib 4x RFA device was used to coagulate a margin of normal parenchyma around the renal mass to allow excision of the mass within a bloodless plane. Unlike in the LPN group, renal hilar vascular occlusion was not performed in the RF-RCPN group. Tumors treated in the RF-RCPN group tended to be larger (2.8 vs. 2.0 cm) and more often endophytic (52.6% vs. 16.1%). Collecting system reconstruction occurred more often in the RF-RCPN group (78.6% vs. 30.6%). Operative duration was longer in the RF-RCPN group (373 vs. 250 minutes), but this included time for cystoscopy, ureteral stenting, and repositioning of the patient. Blood loss, transfusion rates, renal function, and complication rates did not differ between the two groups. No patients required renal hilar vessel clamping or nephrectomy to control bleeding in the RF-RCPN group. The use of RFA-assistance during robotic partial nephrectomy allows excision of renal tumors without hilar vascular clamping, thus eliminating renal warm ischemia. Larger and more centrally located tumors were excised with RF-RCPN. No differences in blood loss, complication rate, postoperative bleeding, renal function, or recurrence rate were noted compared with LPN.

Hybrid Laparoscopic and Robotic Ultrasound-guided Radiofrequency Ablation-assisted Clampless Partial Nephrectomy

To describe a clampless approach made possible by creating an avascular plane of tissue with radiofrequency ablation. Laparoscopic partial nephrectomy is slowly gaining acceptance as a method to treat small (<4 cm) and select moderate (<7 cm) renal masses. The intricacies of laparoscopic suturing, which result in prolonged warm ischemia times, have delayed the widespread acceptance of this technique among urologists. Laparoscopic suturing to close the collecting system was done using the da Vinci robot. An avascular plane of tissue from coagulation necrosis was achieved with the Habib 4X radiofrequency ablation device and the Rita 1500X generator. Typically, we used a power setting of 50 W but have found settings as low as 25 W necessary to provide hemostasis for larger vessels. The tumor was then sharply excised with a negative margin using robotic scissors and electrocautery to facilitate tissue cutting. Retrograde injection of methylthioninium chloride and saline through an externalized ureteral catheter allowed for precise sutured closure of the collecting system. FloSeal and BioGlue were then applied, making surgical bolsters or parenchymal sutures unnecessary. Intraoperative histologic evaluation of the surgical margin and repeat resection of the tumor bed was possible because the renal hilum was not clamped, and no warm ischemia was used. This technique, which combines the improving technologies of robotic surgery, intraoperative laparoscopic ultrasonography, and radiofrequency ablation, might make more surgeons comfortable with the intricacies of laparoscopic suturing and eliminate prolonged warm ischemia times. Overall, this method should result in more patients being able to undergo minimally invasive laparoscopic partial nephrectomy.