Hilar Tumors Research Articles

Intraoperative conversion from partial to radical nephrectomy: Predictive factors and outcomes.

483 Background: Predictive risk factors for intraoperative conversion from partial to radical nephrectomy (RN) are poorly quantified. We evaluated preoperative predictors of conversion in a cohort of patients undergoing planned partial nephrectomy (PN). Methods: A prospectively maintained database was reviewed to identify patients who were scheduled to undergo (open, laparoscopic, or robot-assisted) PN that were converted to RN between 1990 and 2015. Reasons for conversion were collected from the operative report. Patient demographics and perioperative variables were evaluated including body mass index (BMI), tumor size, nephrometry score, hilar tumors, procedure type, intraoperative complications, and oncologic outcome. Results: A total of 2298 patients underwent successful PN. The rate of conversion to RN was 4% (n=99) patients. The median patient age was 60 years and median BMI was 30 kg/m2. The median American Society of Anesthesiologists (ASA) score was 3 and median Charlson Comorbidity Index (CCI) was 2. The median tumor size for the converted cases was 4.5 cm (1.0-10.1) and median nephrometry score was 9. Histology was clear cell-RCC in 79% of the tumors. A total of 30 patients had completely endophytic tumors. The most common reasons for conversion were hilar/renal sinus extension of the renal mass in 38 (38%) patients, positive surgical margin on frozen section or gross assessment in 27 (27%) patients, insufficient renal remnant in 27 (27%) patients, and excessive intraoperative bleeding in 7 (7%) patients. RN was performed open in 79, laparoscopically in 9, and robot-assisted in 11 cases. Intraoperative complications occurred in 1 (1%) patient underwent an attempted robot-assisted PN resulted in an injury to a major renal artery branch requiring conversion to RN. Patients were followed up for a median of 33 months. In the converted cohort, evidence of disease at last follow-up was found in 13 (13%) patients. Conclusions: The rate of conversion to RN was low in patients undergoing PN in this series. The most common reason for conversion was hilar/renal sinus extension of these complex renal masses while positive surgical margin and insufficient renal remnant were contributing equally at lower rates.

Clinical Implications of Cytotoxic T Lymphocyte Antigen-4 Expression on Tumor Cells and Tumor-Infiltrating Lymphocytes in Extrahepatic Bile Duct Cancer Patients Undergoing Surgery Plus Adjuvant Chemoradiotherapy.

There currently is only limited knowledge on the role of tumor-specific immunity in cholangiocarcinoma. This study evaluated the clinical implications of cytotoxic T lymphocyte antigen-4 (CTLA-4) expression levels and CD4+ and CD8+ tumor-infiltrating lymphocytes (TILs) in extrahepatic bile duct (EHBD) cancer. Immunohistochemistry of CTLA-4, CD4, and CD8 was performed for 77 EHBD cancer patients undergoing surgery plus adjuvant chemoradiotherapy. CTLA-4 expression on tumor cells and TILs were assessed by using H-scores and the proportion of CTLA-4+ lymphocytes, respectively. With optimal cutoff values determined by a maximal chi-square method with overall survival (OS) data, patients with CTLA-4 H-score >70 and a proportion of CTLA-4+ TILs >0.15 showed higher mean density of CD8+ and CD4+ TILs, respectively (P = 0.025 for CD8+ and P = 0.055 for CD4+ TILs). The high CTLA-4 H-score level was associated with prolonged OS and disease-free interval (DFI) (P = 0.025 and 0.004, respectively). With differential levels of CTLA-4 H-score according to hilar and non-hilar locations (high rate 32 vs. 68%, respectively; P = 0.013), an exploratory subgroup analysis demonstrated that the associations between the CTLA-4 expression and OS and DFI were confined to hilar tumors (P = 0.003 and <0.001, respectively), but not to non-hilar ones (P = 0.613 and 0.888, respectively). This study demonstrates a potential prognostic relevance of CTLA-4 expression in EHBD cancer. We suggest a differential survival impact of the CTLA-4 expression level according to different tumor locations.

Novel Therapy for Unresectable Hilar Cholangiocarcinoma ‘Klatskin Tumor’ Utilizing Percutaneous Irreversible Electroporation: A Case Report

Unresectable hilar cholangiocarcinoma ‘Klatskin Tumor’ is a rare malignancy with limited treatment options and an overall poor prognosis. Percutaneous Irreversible Electroporation (IRE) is a relatively new ablative procedure with potential for treating unresectable cholangiocarcinoma, improving morbidity, and ultimately prolonging survival. The main benefit of IRE relies in the non-thermal technology which can be considered in patients with hilar tumors given the criticality of the adjacent vessels and bile ducts. This case report describes a 71 year old female with unresectable Bismuth-Corlette Stage IV cholangiocarcinoma who underwent IRE with disease control 13 months after treatment.

22 - Metastatic potential of hilar renal tumors

22 - Metastatic potential of hilar renal tumors

Retroperitoneoscopic Partial Nephrectomy for Moderately Complex Ventral Hilar Tumors: Surgical Technique and Trifecta Outcomes from a Single Institution in China.

T1 ventral renal hilar tumors (VRHTs) represent a very special type of tumor, for which laparoscopic partial nephrectomy (LPN) by the retroperitoneal approach is challenging. In this study, we report our surgical technique and Trifecta results. Renal rotation technique has been established for retroperitoneal laparoscopic partial nephrectomy (RLPN) for VRHTs in our institution. Trifecta was used as a composite outcome measure for assessing quality of PLPN using this technique. A retrospective analysis of RLPN cases in 12 patients with VRHTs was performed. Mean tumor size was 3.4 cm and median R.E.N.A.L. score was 8 (range 7-9). Mean warm ischemia time was 23.1 minutes, suture time 28.1 minutes, estimated blood loss 139.2 mL, operation time 122.8 minutes, and median hospital stay was 4 days. Three patients (25.0%) had Clavien-Dindo grade I-II complications. Seven patients (58.3%) achieved Trifecta. Postoperative pathological examination showed renal cell carcinoma in all cases with negative surgical margin. A median follow-up of 7 months revealed no local recurrence or distant metastases. Our Trifecta outcomes demonstrate that RLPN with renal rotation technique is feasible, safe, and effective for moderately complex VRHTs. The short-term functional and oncologic outcomes are promising; however, long-term follow-up is needed.

V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS

You have accessJournal of UrologyRobotics - Renal1 Apr 2016V9-03 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS Matthew J. Maurice, Daniel Ramirez, Peter A. Caputo, Ryan J. Nelson, Onder Kara, Ercan Malkoc, and Jihad H. Kaouk Matthew J. MauriceMatthew J. Maurice More articles by this author , Daniel RamirezDaniel Ramirez More articles by this author , Peter A. CaputoPeter A. Caputo More articles by this author , Ryan J. NelsonRyan J. Nelson More articles by this author , Onder KaraOnder Kara More articles by this author , Ercan MalkocErcan Malkoc More articles by this author , and Jihad H. KaoukJihad H. Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1194AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Hilar tumors are challenging due to their centrality and proximity to the renal hilum, increasing the complexity of tumor excision and renal reconstruction. We sought to highlight these challenges and demonstrate techniques for successful execution and excellent outcomes. METHODS Using our retrospective robotic partial nephrectomy database, we abstracted data on patients who were treated between 2006 and 2015. Videos demonstrating robotic partial nephrectomy for two particularly challenging hilar tumors were selected for presentation. For all cases, patients were positioned in full 45-degree flank, and surgery was performed with four working ports. Intraoperative ultrasound was used to identify tumor margins and guide excision. The renorrhaphy was performed in a minimum of two layers, including a deep layer closed with 2-0 polyglactin 910 in a running fashion and a capsular layer closed with 0 polyglactin 910 suture in a horizontal mattress fashion. RESULTS Of 1123 total operations, 97 (8.9%) were performed for hilar tumors. Median tumor size was 3.7 cm (IQR, 3.0-4.6), and median RENAL score was 9 (IQR, 8-10). Median estimated blood loss was 200 cc (IQR, 100-300). Median operative and warm ischemia times were 3.3 hours (IQR, 2.7-4.3) and 26 minutes (IQR, 21-33), respectively. The overall complication rate for all tumors was 22.2% (249/1,123), including 183 (16.3%) minor and 66 (5.9%) major complications. For hilar tumors, the complication rate was 30.9% (30/97), including 21 (21.6%) minor and 9 (9.3%) major complications. CONCLUSIONS Robotic partial nephrectomy is technically feasible for highly complex hilar tumors. Operative times and warm ischemia may be prolonged. For select cases, clinical, oncological, and functional outcomes are excellent. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e860 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Matthew J. Maurice More articles by this author Daniel Ramirez More articles by this author Peter A. Caputo More articles by this author Ryan J. Nelson More articles by this author Onder Kara More articles by this author Ercan Malkoc More articles by this author Jihad H. Kaouk More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V5-01 ROBOTIC PARTIAL NEPHRECTOMY FOR INCREASINGLY COMPLEX RENAL MASSES IN SOLITARY KIDNEYS USING OFF CLAMP AND EARLY UNCLAMPING TECHNIQUES

You have accessJournal of UrologyRenal Oncology1 Apr 2016V5-01 ROBOTIC PARTIAL NEPHRECTOMY FOR INCREASINGLY COMPLEX RENAL MASSES IN SOLITARY KIDNEYS USING OFF CLAMP AND EARLY UNCLAMPING TECHNIQUES Manish Patel and Ashok Hemal Manish PatelManish Patel More articles by this author and Ashok HemalAshok Hemal More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.244AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The indications for partial nephrectomy are expanding. The AUA guidelines state that partial nephrectomy is a standard option for healthy patients with clinical T1a and T1b renal masses. While most surgeons can choose the procedure that they are most comfortable with, there are a few imperative indications for partial nephrectomy including solitary kidneys. In this video, we demonstrate our technique of robotic partial nephrecgtomy for patients with solitary kidneys with emphasis of our off clamp and early unclamping techniques to minimize warm ischemia. METHODS Since 2008 we have performed over 450 robotic partial nephrectomies, 12 of which were in solitary kidneys. Our port placement for the da Vinci Si and Xi are in figures 1 and 2. Typically small exopyhtic partial nephrectomies are done off clamp. For more endophytic or hilar tumors, clamping is performed with removal of the clamps as soon as there is hemostasis. For patients with multiple tumors, bulldog clamps are placed with the larger endophytic tumors are done first, then clamps are removed and the smaller and exophytic tumors are removed. Renorrhapy is performed in multiple layers using monocryl for the collecting system and small vessels, and interrupted vicryl for the medulla and cortex. RESULTS The median age of our series was 58 (48-73). The median warm ischemia time was 14 minutes with one ileus and one postoperative urine leak. There were no conversions to open. Postoperatively, 92% of the tumors were malignant with a mean decrease in eGFR of 30% (-68% - 0%) at a median follow up of 32 months. CONCLUSIONS Partial nephrectomy in patient with solitary kidney is a safe and feasible even for complex and multiple masses. The continued spread of technology and techniques may allow more patients to undergo nephron sparing techniques decreasing the risk of CKD and long term morbidity and mortality. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e593-e594 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Manish Patel More articles by this author Ashok Hemal More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Selective Arterial Clamping Versus Hilar Clamping for Minimally Invasive Partial Nephrectomy.

Partial nephrectomy has become an accepted treatment of cT1 renal masses as it provides improved long-term renal function compared to radical nephrectomy (Campbell et al. J Urol. 182:1271-9, 2009). Hilar clamping is utilized to help reduce bleeding and improve visibility during tumor resection. However, concern over risk of kidney injury with hilar clamping has led to new techniques to reduce length of warm ischemia time (WIT) during partial nephrectomy. These techniques have progressed over the years starting with early hilar unclamping, controlled hypotension during tumor resection, selective arterial clamping, minimal margin techniques, and off-clamp procedures. Selective arterial clamping has progressed significantly over the years. The main question is what are the exact short- and long-term renal effects from increasing clamp time. Moreover, does it make sense to perform these more time-consuming or more complex procedures if there is no long-term preservation of kidney function? More recent studies have shown no difference in renal function 6 months from surgery when selective arterial clamping or even hilar clamping is employed, although there is short-term improved decline in estimated glomerular filtration rate (eGFR) with selective clamping and off-clamp techniques (Komninos et al. BJU Int. 115:921-8, 2015; Shah et al. 117:293-9, 2015; Kallingal et al. BJU Int. doi: 10.1111/bju.13192, 2015). This paper reviews the progression of total hilar clamping to selective arterial clamping (SAC) and the possible difference its use makes on long-term renal function. SAC may be attempted based on surgeon's decision-making, but may be best used for more complex, larger, more central or hilar tumors and in patients who have renal insufficiency at baseline or a solitary kidney.

V34 Robotic partial nephrectomy for hilar tumours: Zero ischemia or early unclamping?

V34 Robotic partial nephrectomy for hilar tumours: Zero ischemia or early unclamping?

Institutional Experience in the Management of Hilar Liver Obstruction- A Series of 13 Cases.

Neoplastic hilar obstruction to the liver outflow presents a unique challenge to the surgeon, wherein, the balance between a curative and possibly larger resection has to be achieved against a more conservative local resection. These are often technically demanding and have thus, far produced equivocal outcomes on both ends. The present case series is on 13 patients who presented with hilar obstruction. They all underwent resections with possible curative intent. The focus of our review is on the technical nuances and the strategies we used, intra- and peri-operatively to make resections possible in these patients, who at first look were deemed inoperable. Among the 13, 10 had hilar cholangiocarcinoma (CCA) while the others had a more benign diagnosis e.g., Hydatid disease. We did not encounter any peri-operative mortality in our series. Two of our patients had to be re-explored for intra-abdominal complications. Among the 13, we encountered two deaths. The rest of the patients are still on follow-up as of April 2016. Hilar CCA continue to be rare and challenging tumours for the Hepato Pancreato Biliary (HPB) surgeon to manage. Outlooks are currently changing as we try to resect bigger and more complicated hilar liver tumours with better results.

Pulmonary Hilar Tumor: An Unusual Presentation of Sclerosing Hemangioma.

Pulmonary sclerosing hemangioma is an uncommon benign tumor of the lung; however, on rare occasions it can arise from the pulmonary hilar region. Herein, we report a 53-year-old female patient who presented with a round opacity in the right upper lung field on a radiograph. Chest computed tomography scanning revealed a 3.1 cm mass in the right pulmonary hilum. Thoracoscopic tumor excision was subsequently performed. On pathohistologic study, the tumor was well defined and composed of round stromal cells and surface cells arranged in a papillary, sclerotic, solid, and hemorrhagic pattern. In immunochemical study, the round cells were positive for thyroid transcription factor-1 (TTF-1) and epithelial membrane antigen (EMA) and negative for cytokeratin. The surface cells were positive for TTF-1, EMA, and cytokeratin. Therefore, a final diagnosis of sclerosing hemangioma was confirmed. In conclusion, pulmonary sclerosing hemangioma is uncommon and rare in the pulmonary hilar region. CT scanning is useful to determine its benignity, although imaging features are not specific for a definite differential diagnosis from other pulmonary tumors. Therefore, tissue diagnosis is usually necessary, and pulmonary sclerosing hemangioma should be listed in the differential diagnoses of pulmonary hilar tumors.

Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†.

Locally advanced lung tumours often require complex surgical techniques to achieve an oncological and safe procedure. Sleeve resections when operating on endobronchial lesions or hilar tumours should be attempted whenever possible rather than performing a pneumonectomy. These procedures result in improved survival, better quality of life, a reduced loss of lung function and an improved operative mortality compared with pneumonectomy. Although the most common approach is an open thoracotomy, these complex surgical techniques can be performed in a thoracoscopic way with the skills and the experience gained from major video-assisted thoracoscopic procedures (VATS). However, despite the multiple advantages of VATS compared with thoracotomy, such as decreased postoperative pain and better recovery, this minimally invasive approach is still not widely adopted for advanced stages of lung cancer and complex resections. Concerns about performing an adequate oncological resection and safe reconstruction VATS are the main reasons for the low adoption of these minimally invasive approaches. Like other thoracoscopic techniques, VATS sleeve procedures also have a steep learning curve, and should therefore be performed either by or with skilled and experienced VATS surgeons to ensure safety and avoid complications. In this article, we describe the technique of thoracoscopic sleeve procedures through a single-incision (uniportal) approach for bronchial, bronchovascular, tracheal and carinal reconstruction, and review the literature reporting sleeve resections by VATS.

Is c-Met oncoprotein expression an adverse prognosticator in extrahepatic bile duct cancer treated with curative resection followed by adjuvant chemoradiotherapy?

To analyze the expression of c-Met, and to investigate correlations between the expression of c-Met, clinicopathologic variables, and survival in patients undergoing curative surgery followed by adjuvant chemoradiotherapy for extrahepatic bile duct (EHBD) cancer. Ninety EHBD cancer patients who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled. Expression of c-Met was assessed with immunohistochemical staining on tissue microarray. The correlation between clinicopathologic variables and survival outcomes was evaluated using Kaplan-Meier method and Cox proportional hazard model. On univariate analysis, 66 patients (76.7%) showed c-Met expression. c-Met expression had a significant impact on 5-year overall survival (OS) (43.0% in c-Met(+) vs. 25.0% in c-Met(-), p=0.0324), but not on loco-regional relapse-free survival or distant metastasis-free survival (DMFS). However, on multivariate analysis incorporating tumor location and nodal involvement, survival difference was not maintained (p=0.2940). Tumor location was the only independent prognostic factor predicting OS (p=0.0089). Hilar location tumors, nodal involvement, and poorly differentiated tumors were all identified as independent prognostic factors predicting inferior DMFS (p=0.0030, 0.0013, and 0.0037, respectively). This study showed that c-Met expression was not associated with survival outcomes in EHBD cancer patients undergoing curative resection followed by adjuvant chemoradiotherapy. Further studies are needed to fully elucidate the prognostic value of c-Met expression in these patients.

Robot-assisted Partial Nephrectomy for Endophytic Tumors.

Robot-assisted partial nephrectomy (RAPN) has gained increasing popularity in the management of renal masses due to its technical feasibility and shorter learning curve with superior perioperative outcomes compared to laparoscopic partial nephrectomy (LPN). Given the cumulation of surgical experience on RAPN, the indication for RAPN has been extended to more challenging, complex cases, such as hilar or endophytic tumors. Renal masses that are completely endophytic can be very challenging to surgeons. These cases are associated with poor recognition of mass extension, higher risk of inadvertent vascular, or pelvicalyceal system injury. As a result, this can lead to potential positive surgical margin, difficulty in performing renorrhaphy as well as higher perioperative complication rates. There is few evidence of oncologic and functional outcomes of RAPN on treating endophytic masses. Therefore, the objective of this review is to critically analyze the current evidence and to provide a summary on the outcomes of RAPN for endophytic renal masses.

Accuracy of Contrast-Enhanced Ultrasound in the Diagnosis of Bile Duct Obstruction.

To investigate the ability of contrast-enhanced ultrasound (CEUS) to differentiate benign from malignant lesions causing biliary duct obstruction. Between November 2006 and December 2013, 59 patients with bile duct obstruction of undetermined cause in baseline ultrasound underwent CEUS study. The enhancement and posterior washout were analyzed in real time all along the study duration (5'). The final diagnosis suggested by CEUS was compared with histologic diagnosis (47.5%) or with radiologic follow-up with TC, RM or ERCP. Final diagnoses included 42 malignant lesions (cholangiocarcinoma n=22, metastases n=6, pancreatic carcinoma n=6, hepatocarcinoma n=4, gallbladder carcinoma n=2, ampullary carcinoma n=1 and lymphoma n=1) and 17 benign lesions (lithiasis or biliary sludge n=15, xanthogranulomatous cholecystitis n=1 and indeterminate n=1). CEUS accuracy compared with final diagnoses based on combined reference standard was 86.4%. CEUS correctly identified 36 of 42 malignant lesions (sensibility 85.7%) and 15 of 17 benign lesions (specificity 88.2%). The positive predictive value of CEUS for malignancy was 94.7%, while the negative predictive value was 71.4%. CEUS is useful to differentiate between benign and malignant causes of obstructive jaundice. This technique improves the detection of bile duct invasion in hepatic neoplasms and permits better evaluation of intra- and extraductal extension of hilar hepatobiliary tumors.

Functional and oncological outcomes of open nephron-sparing surgery for complex renal masses

ObjectiveTo present our long-term functional and oncological outcomes in open nephron-sparing surgery for complex renal masses. Patients and methodsWe enrolled 584 patients who underwent open partial nephrectomy between January 1995 and May 2014 at our institution; 108 (18.4%) patients had hilar or completely intraparenchymal tumors or both. We compared change in renal function, perioperative complications, and survival outcomes between complex and noncomplex renal masses. ResultsMean tumor diameter was 4.3 and 3.5cm in patients with hilar and completely intraparenchymal lesions, respectively. R.E.N.A.L. nephrometry scores were significantly higher in patients with complex tumors as compared with patients with exophytic tumors. There was no significant difference between mean estimated glomerular filtration rate at last follow-up compared with preoperative mean estimated glomerular filtration rate in any of the groups. The incidence of perioperative complications was similar across all patients groups. Estimated 10-year cancer-specific survival probabilities were 100% in patients with hilar and intraparenchymal tumors. The 10-year recurrence-free survival probabilities were 96% and 95% in patients with hilar and intraparenchymal tumors, respectively. The main limitations include retrospective design and the lack of kidney-specific functional scan. ConclusionOpen nephron-sparing surgery should be considered for complex renal masses yielding excellent functional and oncological outcomes without higher incidence of complications.

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: Perioperative ouctomes

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: Perioperative ouctomes

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: perioperative ouctomes

Robotic-assisted partial nephrectomy for hilar and non-hilar tumors: perioperative ouctomes

V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING?

You have accessJournal of UrologyRobotics – Renal1 Apr 2015V9-06 ROBOTIC PARTIAL NEPHRECTOMY FOR HILAR TUMORS: ZERO ISCHEMIA OR EARLY UNCLAMPING? Benoit Peyronnet, Quentin Alimi, Tarek Fardoun, Romain Mathieu, Gregory Verhoest, and Karim Bensalah Benoit PeyronnetBenoit Peyronnet More articles by this author , Quentin AlimiQuentin Alimi More articles by this author , Tarek FardounTarek Fardoun More articles by this author , Romain MathieuRomain Mathieu More articles by this author , Gregory VerhoestGregory Verhoest More articles by this author , and Karim BensalahKarim Bensalah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2281AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES An arterial clamping is usually performed during partial nephrectomy in order to decrease blood loss and improve vision during tumorectomy. However, it causes warm ischemia which is potentially harmful for the kidney. The concept of “zero ischemia” robotic partially nephrectomy appeared in the early 2010's. Its aim is to avoid warm ischemia time by omitting to clamp the main renal artery. The aim of this video was to compare two managements of the renal pedicle during robotic partial nephrectomy for hilar tumors: early unclamping vs. zero ischemia. METHODS We present 2 cases of robotic partial nephrectomy for complex (RENAL NEPHROMETRY score ≥ 7) and hilar tumors. In the first case, a 6 cm tumor of the left kidney has been diagnosed in a 57 year-old male. RENAL NEPHROMETRY score was 10-ph. The main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen. RESULTS In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved. In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved. CONCLUSIONS Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (< 30 minutes) could have no impact on renal function, the early unclamping technique, which appear safer, could be the preferred option in these patients. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e776-e777 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Quentin Alimi More articles by this author Tarek Fardoun More articles by this author Romain Mathieu More articles by this author Gregory Verhoest More articles by this author Karim Bensalah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V9-08 ROBOTIC-ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY AND IPSILATERAL PYELOLITHOTOMY IN INTRARENAL PELVIS

main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen. RESULTS: In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved. In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved. CONCLUSIONS: Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (< 30 minutes) could have no impact on renal function, the early unclamping technique, which appear safer, could be the preferred option in these patients.