Renal Hilar Control Research Articles

Case report: A hybrid technique for a safe nephrectomy in a giant kidney angiomyolipoma

BackgroundGiant angiomyolipoma is usually associated with genetic syndromes and complications (spontaneous rupture and bleeding, hematuria, hypertension) and mass-related symptoms (flank and abdominal pain).Case presentationWe present a case of a 20-year-old woman suffering from tuberous sclerosis who was referred to our hospital with a giant angiomyolipoma causing abdominal pain. A contrast-enhanced computed tomography showed a left angiomyolipoma, measuring 28 cm × 17 cm × 27 cm. After a multidisciplinary team discussion, the patient was submitted for a nephrectomy. Percutaneous temporary occlusion of the main renal artery was achieved through an endovascular balloon catheter. Through the balloon catheter guidewire, 2,500 IU of heparin was infused to reduce the risk of tumor vein thrombosis and venous embolism. This allowed a safe kidney manipulation through a left thoracoabdominal approach. The postoperative course was uneventful. Pathology showed a 40 cm × 30 cm × 9 cm and 10 kg AML. One year after surgery, the patient is on follow-up, and her estimated glomerular filtration is 120.5 ml/min/1.73 m2.ConclusionThe present case showed that the endovascular control of the main renal artery could be considered a useful approach to safely managing huge renal masses when renal hilar control is expected to be very difficult.

Open versus robotic partial nephrectomy: Systematic review and meta‐analysis of contemporary studies

To compare perioperative outcomes of robotic-assisted partial nephrectomy (RaPN) with open partial nephrectomy (OPN). Systematically search through PubMed, Embase, ClinicalKey, Cochrane Library, ProQuest, ScienceDirect, Web of Science, and ClinicalTrials.gov for eligible studies was performed to April 11, 2018. A meta-analysis was conducted for studies comparing RaPN and OPN. Confounding variables were assessed by meta-regression or subgroup analysis. This study included 34 studies with 60808 patients. Meta-analysis revealed less blood loss, less transfusion, longer operative time, less postoperative complications, lower readmission rate, shorter length of stay, and less estimated glomerular filtration rate (eGFR) decline in RaPN groups. The superiority of RaPN in blood loss was attenuated with highly complex renal masses. The superiority of RaPN in intraoperative complications was strengthened with renal hilar control. The advantage of RaPN in surgical margin was increased in patient with body mass index (BMI)<28. Compared with OPN, RaPN provided lower morbidities and better renal function preservation.

Robotic Left-sided Level II Caval Thrombectomy and Nephrectomy Using a Novel Supine, Single-dock Approach: Primary Description

To demonstrate a novel supine, single-dock approach for robotic nephrectomy and inferior vena cava (IVC) thrombectomy for a left-sided renal cell carcinoma with level II IVC thrombus. We perform robotic nephrectomy and IVC thrombectomy in a 79-year-old man with a 6-cm left renal mass and level II IVC thrombus. For this approach, the patient is placed in steep Trendelenburg, and a 6-port transperitoneal technique is used, with the robot docked such that the arms are oriented in a cephalad direction. We describe key steps, including (1) exposure of the retroperitoneum, (2) IVC exposure and control, (3) left renal hilar control, (4) cavotomy, thrombectomy, and reconstruction, (5) nephrectomy and lymph node dissection. Perioperative outcomes are reported. Robotic left nephrectomy and level II IVC thrombectomy were successfully completed using this novel, single-dock approach. Total operative time was 7 hours with IVC clamp time of 27 minutes. Estimated blood loss was 500 cc without perioperative transfusion. There were no intraoperative or major perioperative complications. The patient was discharged on postoperative day 5. This approach allows rapid caval control, bilateral renal hilar access, and obviates the need for preoperative renal artery embolization or intraoperative redocking or repositioning steps, as has been previously described for other approaches. We demonstrate the first description of robotic left-sided level II IVC thrombectomy and radical nephrectomy using a supine, single-dock approach. This novel, versatile approach adds to the armamentarium for minimally invasive surgical management of renal cell carcinoma with IVC thrombus.

V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH

You have accessJournal of UrologyRenal Oncology1 Apr 2017V3-03 ROBOTIC LEFT-SIDED LEVEL II CAVAL THROMBECTOMY AND NEPHRECTOMY: PRIMARY DESCRIPTION OF NOVEL SUPINE, SINGLE-DOCK APPROACH Monty Aghazadeh, Spencer Craven, and Alvin Goh Monty AghazadehMonty Aghazadeh More articles by this author , Spencer CravenSpencer Craven More articles by this author , and Alvin GohAlvin Goh More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.718AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Initial descriptions of robotic management of renal cell carcinoma with Inferior Vena Cava (IVC) thrombus employ a lateral approach predicated on early IVC exposure and control. However, for left-sided renal masses and associated tumor thrombi, this approach requires re-positioning and re-docking steps, as well as pre-operative left renal artery embolization. Herein, we describe a novel supine, single dock technique for robotic left nephrectomy and caval thrombectomy. METHODS We perform robotic nephrectomy and caval thrombectomy on a 79 y.o. male with a 6cm left renal mass and level II IVC thrombus. The patient is placed supine, in steep trendelenburg. We employ a 6-port trans-peritoneal technique and dock the robot such that arms are directed cephalad. Key steps critical to the procedure include: 1) Exposure of the retroperitoneum 2) IVC exposure and control 3) Left Renal Hilar Control 4) Cavotomy, thrombectomy, and reconstruction 5) Nephrectomy and lymph node dissection (LND). Peri-operative outcomes are reported and compared to previously published case series. RESULTS Robotic left nephrectomy and level II caval thrombectomy was performed successfully via a single-dock, supine approach. This method yielded excellent and early access to the IVC and left renal hilum, and allowed for concomitant nephrectomy/LND without re-positioning. Total operative time was 420 minutes with 330 minutes robotic console time (174 minutes for exposure, 27 minutes IVC clamp time, 84 minutes for nephrectomy/LND). EBL was 500cc without need for peri-operative transfusions and no intraoperative complications. Length of stay was 5 days and no major perioperative complications were noted. Outcomes compare favorably to previously reported robotic caval thrombectomy procedures employing the lateral approach. CONCLUSIONS We demonstrate successful robotic left nephrectomy with Level II caval thrombectomy using a supine, single-dock approach. To our knowledge, this is the first description of this approach for robotic caval thrombectomy. In appropriately selected patients, this versatile approach allows for rapid caval control, bilateral renal hilar access, and obviates the need for patient re-positioning. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e288-e289 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Monty Aghazadeh More articles by this author Spencer Craven More articles by this author Alvin Goh More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Laparoscopic Partial Nephrectomy With Segmental Renal Artery Clamping: Technique and Clinical Outcomes

BackgroundWarm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy (PN). The technique of segmental renal artery clamping emerges as an alternative to conventional renal artery clamping for renal hilar control. ObjectiveTo evaluate the feasibility and efficiency of laparoscopic PN (LPN) with segmental renal artery clamping in comparison with the conventional technique. Design, setting, and participantsA total of 75 patients underwent LPN from June 2007 to November 2009. All patients had T1a or T1b tumor in one kidney and a normal contralateral kidney. Thirty-seven patients underwent surgeries with main renal artery clamping, and 38 underwent surgeries with segmental artery clamping. InterventionAll procedures were performed by the same laparoscopic surgeon. MeasurementsBlood loss, operation time, warm ischemia (WI) time, and complications affected renal function before and after operation were recorded. Results and limitationsAll LPNs were completed without conversion to open surgery or nephrectomy. The novel technique slightly increased WI time (p<0.001) and intraoperative blood loss (p=0.006), while it provided better postoperative affected renal function (p<0.001) compared with the conventional technique. The total complication rate was 12%. Among the 38 cases where segmental renal artery clamping was performed, 7 had to convert to the conventional method. Tumor size and location influenced the number of clamped segmental arteries. Long-term postoperative renal function is still awaited. ConclusionsLPN with segmental artery clamping is safe and feasible in clinical practice. It minimizes the intraoperative WI injury and improves early postoperative affected renal function compared with main renal artery clamping.

Renal Hilar Control During Laparoscopic Partial Nephrectomy: To Clamp or Not to Clamp

To decrease intraoperative and perioperative morbidity that is associated with laparoscopic partial nephrectomy (LPN), clamping of the renal hilum has been advocated. It has been suggested, however, that renal hilar control is not necessary in all patients. We compared the perioperative and pathologic results of 21 consecutive patients who underwent LPN with or without renal hilar clamping at our institution. Twenty-one patients underwent LPN over a 24-month period. Of these, 11 LPNs were completed without hilar control while 10 needed hilar clamping. Renal hilar control was deemed necessary if the depth of tumor invasion was greater than 50% of the renal parenchyma on CT or MRI. Only the artery was clamped. We retrospectively analyzed the intraoperative, perioperative, and the pathologic results. The mean tumor size was 2.6 cm (range 0.8-4.2 cm) in the nonclamped group and 2.3 cm (range 1.5-3 cm) in the clamped group. The mean operative time was 174 minutes (range 95-270 min) in the nonclamped group and 232 minutes (range 180-270 min) in the clamped group. The mean ischemia time was 29 minutes (range 21-45 min) in the clamped group. The mean postoperative serum creatinine level was 1.1 mg/dL (range 0.7-2.0 mg/dL) in the nonclamped and 1.1mg/dL (range 0.7-1.8 mg/dL) in the clamped group. Postoperative transfusion was not needed. In one patient in the nonclamped group and in three patients in the clamped group, urine leak occurred. In the nonclamped group, 7 of the 11 procedures were for benign tumors while only 2 of the 10 lesions in the clamped group were benign. LPN can be performed safely in selected patients without clamping the hilum. Tumors that need cross-clamping of the renal hilum were more likely to be malignant. We suggest that the decision to clamp the hilar vessels should be made based on each patient's characteristics and radiologic findings.

Preferred management option for small renal masses: laparoscopic partial nephrectomy

Preferred management option for small renal masses: laparoscopic partial nephrectomy

Robotic Renal Hilar Control and Robotic Clip Placement for Partial Nephrectomy

We demonstrate two techniques in this video clip that can be used when performing robotic-assisted laparoscopic partial nephrectomy. First, we use the fourth arm of the robot with a long-tip grasper to occlude the renal artery during the resection of the mass. Second, we show a novel method for securing the mattress sutures when performing the repair of the kidney. Both maneuvers help to increase the safety of the procedure and decrease the warm ischemia time to the kidney.

Are Titanium Clips for Control of the Renal Hilar Vessels as Unsafe as Generally Presumed?

Controlled ligation and division of renal vessels is a critical step during any nephrectomy procedure. It is generally been presumed that titanium clip ligation of renal vessels is risky and insecure. We report our experience over 5 years with ligaclips 10-mm titanium clips for secure ligation of renal hilum during laparoscopic nephrectomy. Titanium clips of 10 mm were used to secure renal vessels in 86 patients. We managed to get across the entire width of renal vein with a 10-mm titanium clip by crimpling the vein with the help of the clip applicator before firing the clips. In all except 2 cases ligaclips alone were enough to ensure secure occlusion of renal hilum. There was no incidence of slippage or dislodgement of clips applied on renal vessels. On cost analysis, it was found that the Hem-o-lok clip and gastrointestinal anastomosis stapling device were approximately 6-fold and 12-fold costlier than ligaclips. We also reviewed literature on different modalities available for renal hilar control during laparoscopic nephrectomy.

PROSPECTIVE RANDOMIZED COMPARISON OF TRANSPERITONEAL VERSUS RETROPERITONEAL LAPAROSCOPIC RADICAL NEPHRECTOMY

We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.