Selective Arterial Clamping Research Articles

A Bosniak III Cyst Unmasking Tubulocystic Renal Cell Carcinoma in an Adolescent: Management with Selective Arterial Clamping and Robotic Enucleation

The Bosniak classification of renal cysts aims to provide a probabilistic risk assessment indicating the likelihood of malignancy from imaging findings. Originally designed to classify adult renal cysts based on computed tomography findings, the Bosniak classification has been extended to pediatric patients, with some adjustments made with the aim of accommodating magnetic resonance imaging (MRI) and ultrasonography (US). Bosniak IV lesions are rare in adolescents, indicating localized renal cell carcinoma and requiring surgical intervention. In contrast, Bosniak III lesions can be treated conservatively, although there is a lack of specific guidelines on their management. We present a case of a 14-year-old boy with a Bosniak III lesion, which was incidentally detected during the US evaluation of a left varicocele. After a 12-month follow-up, MRI revealed progression to a Bosniak IV cyst. Robot-assisted tumor enucleation was performed with selective artery clamping when the patient was 15. Histopathology showed tubulocystic renal cell carcinoma without adverse features. Immunocytochemistry supported a favorable prognosis of this rare tumor (<1% of renal tumor), thus obviating the need for adjuvant treatment. At the 18-month follow-up, no recurrence or distant metastasis were observed. This case highlights the importance of an aggressive treatment in persistent Bosniak III and Bosniak IV renal cysts in children and adolescents and the necessity to offer a nephron-sparing surgery.

393 Cerebral Oximetry Using the USIC Protocol Is a Reliable Tool for Indicating Selective Intraluminal Shunting During Carotid Endarterectomy

INTRODUCTION: Indication to selective shunting during carotid endarterectomy (CEA) is based on monitoring during the procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) is one of the monitoring tools but no clear cut off value for an intraluminal shunt insertion has been established. METHODS: 125 patients underwent CEA under LA and were monitored clinically through the whole procedure. The patients also underwent bilateral NIRS monitoring during the surgery. During the monitoring period, we first clamped the external carotid artery (ECA), and after a 1 minute delay followed by clipping the internal carotid artery (ICA). The decrease in the cerebral oximetry values was analyzed separately after selective ICA clipping (ÚstÍ Selective Internal carotid artery Clamping “USIC” protocol). The decision to use a shunt was based solely on clinical symptomatology but the NIRS data were recorded and analyzed. All patients underwent DWI before and after CEA. RESULTS: One hundred and six patients (85%) underwent CEA without clinical deterioration while 19 patients (15%) clinically deteriorated during surgery. The mean drop in the cerebral oximetry after selective ICA clamping in clinically stable patients was 6% while in patients with clinical deterioration the NIRS decreased by 15% (p < 0.05). When we set the cut-off value for selective shunting as a 10% decrease of the ipsilateral cerebral oximetry after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83%. CONCLUSIONS: Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cut-off for selective shunting during CEA. More, bilateral NIRS monitoring allows differentiation between systemic or local events leading to brain hypoxia.

Retroperitoneal laparoscopic partial nephrectomy with selective renal artery clamping for renal cell carcinoma: initial outcomes.

To explore the feasibility and safety of retroperitoneal laparoscopic partial nephrectomy (RLPN) with selective artery clamp (SAC) in patients with renal cell carcinoma (RCC). The authors recruited three men and two women who underwent RLPN for T1 RCC between December 2022 and May 2023 at a tertiary hospital. The median age of the patients was 32 years (range, 25-70years). The tumour size ranged from 3 to 4.5cm. The R.E.N.A.L scores were 4x, 5p, 8a, 5a, and 8ah. The median preoperative eGFR was 96.9 (74.3-105.2). Renal computed tomography angiography was performed before the surgery to evaluate the artery branches. The operation time, number of clamped arteries, warm ischaemic time (WIT), intraoperative blood loss, RCC type, postoperative hospital stay, changes in renal function, and complications were evaluated. The follow-up duration was 6 months. The median operation time was 120 (75-150) minutes. One artery was clamped in four patients, while three were clamped in one patient. The median WIT was 22 (15-30) min, and the median blood loss was 150 (100-300) ml. No complications were recorded, and the resection margin was negative in all patients. The median decrease in eGFR was 6 (4-30%). RLPN with SAC for T1 RCC is safe and feasible in clinical practice.

Robot-assisted Partial Nephrectomy With Selective Artery Clamping for Renal Cell Carcinoma in Horseshoe Kidney.

Robot-assisted partial nephrectomy (RAPN) has become the standard treatment for small renal tumors, including highly complex cases. However, applying RAPN to renal tumors in the horseshoe kidney (HSK) is clinically challenging due to malformations and complex blood supply. Herein, we present two cases of RAPN in patients with HSK treated using selective artery clamping methods. A 61-year-old male with a 15 mm renal tumor located on the upper pole of the right HSK was referred to our Department. The patient underwent RAPN via the transperitoneal approach, following a three-dimensional computed tomography (3D-CT) assessment. Additionally, before surgery, we confirmed which renal arteries would be clamped in surgery by examining the kidney regions supplied by each renal artery. The second patient referred to our Department, a 45-year-old male, had a 46 mm renal tumor located on the isthmus of the HSK. His tumor received blood supply from two renal arteries, with the bilateral collecting systems converging and forming a ureter on 3D-CT. The patient underwent RAPN through an intraperitoneal approach in the semi-lateral position, with port placement lower than in standard RAPN. Pathological examinations revealed clear-cell renal cell carcinoma with negative surgical margins in both cases. Both patients had no recurrences or metastases at 53 and 13 months post-surgery, respectively. We present cases successfully treated with RAPN with selective artery clamping methods for HSK using 3D-CT without encountering complications, even in isthmus tumors.

Dựng hình ba chiều mạch máu thận hỗ trợ lên kế hoạch phẫu thuật cắt một phần thận sử dụng kỹ thuật kẹp chọn lọc nhánh động mạch thận: Nhân một trường hợp lâm sàng

Tóm tắt Các tiến bộ về chẩn đoán hình ảnh với sự hỗ trợ của trí thông minh nhân tạo (AI) đã giúp mang lại nhiều thông tin hỗ trợ chẩn đoán và lên kế hoạch điều trị bướu thận như hình ảnh ba chiều về mạch máu thận. Chúng tôi trình bày một trường hợp bệnh nhân nữ 54 tuổi có bướu thận trái giai đoạn cT1bN0M0. Hình ảnh của khối bướu và hệ thống động mạch thận cùng bên được dựng hình 3D bằng phần mềm (Fujifilm's Synapse® AI Platform) hỗ trợ quá trình lập kế hoạch phẫu thuật. Hình ảnh chụp cắt lớp vi tính cho thấy bướu thận ở cực dưới của thận trái. Sử dụng robot Da vinci Si, chúng tôi đã thực hiện kẹp động mạch thận chọn lọc để cắt một phần thận. Abstract Case presentation: Advances in diagnostic imaging and simulation modeling with the support of artificial intelligence has helped bring a lot of information to support the diagnosis of tumor and treatment planning as a three-dimensional image of the renal vasculature. Thanks to 3D visualization of the renal vasculature, the surgeon can identify the artery supplying the tumor and selectively control this vessel instead of controlling the entire main renal artery. We present a case of 54-year-old woman who diagnosed with left renal tumor staging cT1bN0M0. The image of the tumor and ipsilateral renal artery system was rendered by software (Fujifilm's Synapse® AI Platform) that support the surgical planning. Combined with the advantages of surgical robots, we are fully capable of accessing and selectively controlling the blood vessels feeding the tumor, thereby limiting the impact of warm ischemia time. Keywords: Renal cell carcinoma, renal artery reconstruction, robot assisted surgery, segmental renal artery clamping technique, warm ischemia time.

The Association of Ischemia Type and Duration with Acute Kidney Injury after Robot-Assisted Partial Nephrectomy.

Acute kidney injury (AKI) after robot-assisted partial nephrectomy (RAPN) is a robust surrogate for chronic kidney disease. The objective of this study was to evaluate the association of ischemia type and duration during RAPN with postoperative AKI. We reviewed all patients who underwent RAPN at our institution since 2011. The ischemia types were warm ischemia (WI), selective artery clamping (SAC), and zero ischemia (ZI). AKI was defined according to the Risk Injury Failure Loss End-Stage (RIFLE) criteria. We calculated ischemia time thresholds for WI and SAC using the Youden and Liu indices. Logistic regression and decision curve analyses were assessed to examine the association with AKI. Overall, 154 patients met the inclusion criteria. Among all RAPNs, 90 (58.4%), 43 (28.0%), and 21 (13.6%) were performed with WI, SAC, and ZI, respectively. Thirty-three (21.4%) patients experienced postoperative AKI. We extrapolated ischemia time thresholds of 17 min for WI and 29 min for SAC associated with the occurrence of postoperative AKI. Multivariable logistic regression analyses revealed that WIT ≤ 17 min (odds ratio [OR] 0.1, p < 0.001), SAC ≤ 29 min (OR 0.12, p = 0.002), and ZI (OR 0.1, p = 0.035) significantly reduced the risk of postoperative AKI. Our results confirm the commonly accepted 20 min threshold for WI time, suggest less than 30 min ischemia time when using SAC, and support a ZI approach if safely performable to reduce the risk of postoperative AKI. Selecting an appropriate ischemia type for patients undergoing RAPN can improve short- and long-term functional kidney outcomes.

Off-clamp robotic-assisted partial nephrectomy: surgical experience from a single centre.

Robot-assisted partial nephrectomy (RAPN) is a minimally invasive treatment for localized renal tumours, which can sometimes result in extended warm ischaemic time and serious complications. This study reports on surgical outcomes including feasibility, positive margins, and complications during and after surgery. From January 2011 to November 2022, a single centre performed off-clamp sutureless RAPN on 287 patients. The study recorded preoperative patient characteristics, estimated glomerular filtration rate, and tumour features according to the preoperative aspects and dimensions used for an anatomical (PADUA) classification, and utilized the RENAL nephrometry scoring system. Intraoperative details and complications were documented. Postoperative complications within 30 days were classified according to the Clavien-Dindo system. Follow-up appointments were scheduled at 1, 3, and 6 months in the first year, followed by subsequent appointments every 6 months, and then annually. The study included 145 males and 142 females, with a mean age of 58.9 years and a mean body mass index of 26.7 kg/m2. The mean PADUA score was 8.3, the average console time was 83 minutes, and the estimated blood loss was 280 mL. The average hospital stay was 3 days, and no intraoperative complications were observed. However, 4 patients (1.4%) experienced post-operative haemorrhage that required laparotomy (Clavien-Dindo stage IIIB), and 4 patients (1.4%) had positive surgical margins. Off-clamp selective arterial clamping during minimally invasive partial nephrectomy is a safe and feasible approach for small renal tumours. Further randomized prospective studies are required to confirm if RAPN without clamping offers any renal functional benefits and reduces perioperative bleeding complications.

Clinical analysis of three-dimensional surgical planning system for guiding robot-assisted selective artery clamping partial nephrectomy in completely endophytic renal tumor

Objective: To examine the safety and feasibility of three-dimensional (3D) surgical planning system for guiding robot-assisted selective artery clamping partial nephrectomy (RASPN) in completely endophytic renal tumor. Methods: Clinical data of 32 patients who suffered from completely endophytic renal tumor and underwent RASPN associated with 3D surgical planning system in Department of Urology, Sun Yat-Sen University Cancer Center from November 2018 to August 2021 were analyzed retrospectively. There were 21 males and 11 females, with the age (M (IQR)] of 45.0 (17.5) years (range: 30 to 68 years). Fifteen tumors were located on the left and 17 on the right. Maximum tumor diameter, R.E.N.A.L. Score and preoperative estimated glomerular filtration rate (eGFR) were 27.5 (13.0) mm (range: 14 to 50 mm), 10.0 (1.8) (range: 7 to 11), and 105.5 (15.7) ml·min-1·(1.73 m2)-1 (range: 71.1 to 124.8 ml·min-1·(1.73 m2)-1), respectively. The 3D reconstruction before RASPN was performed in all patients to formulate surgical planning, mainly including stereo localization of renal mass, confirmation of tumor feeding artery, and injury prediction of collecting system or vessel via "2 mm distance method" defined as probable damage of renal pelvis/calyx and artery/vein when these tissues were less than 2 mm away from tumor. Results: Totally 32 patients successfully underwent RASPN guided by 3D surgical planning system, without conversion to open operation or radical nephrectomy. Rapid location of tumor and selective clamping of artery were achieved in all cases and no one encountered global ischemia, with branch occlusion time of 24.5 (15.4) min (range: 12 to 60 min) and coincidence rate of 95.0% (57/60) between planned and actual clamping vessels. The sensitivity and specificity of 2 mm distance method for predicting the injury of collecting system were 13/15 and 17/17, respectively. The operating time of 185 (48) minuetes (range: 76 to 295 minutes) and estimated blood loss of 200 (350) ml (range: 20 to 800 ml) were observed, without intraoperative transfusion case. There was one patient performed with renal vein repair. Clavien-Dindo postoperative grade Ⅱ and Ⅲa bleeding complications occurred in 2 cases, and no postoperative urinary fistula was found. The length of hospitalization was 3 (0) days (range: 2 to 10 days). The pathological diagnosis demonstrated 4 chromophobe cell carcinomas and 2 angiomyolipomas, besides 26 clear cell carcinomas including one positive surgical margin. The postoperative latest eGFR was 103.9(18.5) ml·min-1·(1.73 m2)-1 (range: 75.8 to 122.3 ml·min-1·(1.73 m2)-1) and no tumor recurrence or metastasis was detected during the follow-up time of 15.4 (13.9) months (range: 3 to 35 months). Conclusion: For RASPN in completely endophytic renal tumor, 3D surgical planning system is contributed to determining mass position, defining tumor feeding artery, and predicting collecting system/vessel injury, which benefited precise tumor resection, postoperative renal function preservation, and perioperative urinary fistula and bleeding complication decrease.

V48 - Predicting selective arterial clamping strategy in robot assisted partial nephrectomy using 3d simulations

V48 - Predicting selective arterial clamping strategy in robot assisted partial nephrectomy using 3d simulations

V04-07 3D SELECTIVE ARTERIAL CLAMPING IN ROBOT ASSISTED PARTIAL NEPHRECTOMY

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-07 3D SELECTIVE ARTERIAL CLAMPING IN ROBOT ASSISTED PARTIAL NEPHRECTOMY Pieter De Backer, Melle Belgium, Saar Vermijs, Charles Van Praet, Sarah Vandenbulcke, Maryse Lejoly, Stefanie Vanderschelden, Pieter De Visschere, Alexandre Mottrie, Charlotte Debbaut, and Karel Decaestecker Pieter De BackerPieter De Backer More articles by this author , Melle BelgiumMelle Belgium More articles by this author , Saar VermijsSaar Vermijs More articles by this author , Charles Van PraetCharles Van Praet More articles by this author , Sarah VandenbulckeSarah Vandenbulcke More articles by this author , Maryse LejolyMaryse Lejoly More articles by this author , Stefanie VanderscheldenStefanie Vanderschelden More articles by this author , Pieter De VisscherePieter De Visschere More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , Charlotte DebbautCharlotte Debbaut More articles by this author , and Karel DecaesteckerKarel Decaestecker More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Selective arterial clamping (SAC) in Robot-Assisted Partial Nephrectomy (RAPN) can be considered a good intermediate between an off-clamp and fully-clamped approach, minimizing the risks of bleeding, prolonged warm ischemia time (WIT) and renal function decline. Preoperative estimation of renal perfusion zones and SAC-strategy can be impractical when solely based on CT or MRI images. We describe our mathematical 3D model to preoperatively estimate and visualize the 3D SAC strategy and compare this with peri-operative outcomes of two RAPN cases. METHODS: Two patients with a single renal tumor (PADUA score 6 and 8) underwent RAPN with 3D SAC prediction. 3D arterial tree, parenchyma and tumor volume segmentations derived from preoperative four phase CT scans are inputted in our in-house developed software package. This assigns every voxel of the scanned renal volume to its nearest vessel. The result is an interactive virtual 3D render of different SAC strategies. Intra-operative visualization is performed using the TilePro™ function. After SAC, indocyanine green (ICG) is administered to check the prediction of the algorithm by assessing the renal surface information using Firefly™ fluorescence imaging. RESULTS: Both RAPN conducted according to the preoperatively defined SAC strategy were completed successfully. Dissection time was 19 and 35 minutes for the second generation renal arteries on a total surgical console time of respectively 100 and 110 minutes. Trifecta was achieved twice: negative cancer margin, no renal function decrease (GFR at day 30: resp. >60 and 89 ml/min) and no urological postoperative complications at day 1 and day 30. WIT was 15 and 18 minutes, blood loss 200 and 50 ml, respectively. Histopathology showed oncocytoma in both cases. The ICG fluorescence confirmed correct algorithmic predictions at the surface level. Respectively 16% and 57% of the renal volume was estimated to be clamped simultaneously. The model allowed for bloodless enucleation initiation away from the remaining perfused tumor zone and predicted correctly where bleeding was to be expected inside the parenchyma. CONCLUSIONS: We demonstrated the added value of 3D reconstructions and our predefined 3D SAC strategy in selected cases. A direct distance algorithm specifies the clamping positions and the corresponding perfusion zones. Visualizing this SAC strategy on the 3D reconstruction of the kidney and surrounding structures allows for a targeted approach during the RAPN procedure. Further validation of our predictions is needed and a more systematic approach to measure clinical outcome is desired. Source of Funding: VLAIO mandate HBC.2020.2252 / Orsi Academy / Ipsen Research Grant © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e293-e293 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Pieter De Backer More articles by this author Melle Belgium More articles by this author Saar Vermijs More articles by this author Charles Van Praet More articles by this author Sarah Vandenbulcke More articles by this author Maryse Lejoly More articles by this author Stefanie Vanderschelden More articles by this author Pieter De Visschere More articles by this author Alexandre Mottrie More articles by this author Charlotte Debbaut More articles by this author Karel Decaestecker More articles by this author Expand All Advertisement Loading ...

V04-11 RENAL CELL CARCINOMA IN A HORSESHOE KIDNEY TREATED WITH INDOCYANINE GREEN ASSISTED ROBOTIC HEMINEPHRECTOMY: A REPORT OF TWO CASES

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-11 RENAL CELL CARCINOMA IN A HORSESHOE KIDNEY TREATED WITH INDOCYANINE GREEN ASSISTED ROBOTIC HEMINEPHRECTOMY: A REPORT OF TWO CASES Vikram Lyall, Michael Goltzman, Stuart Kesler, and Benjamin Ristau Vikram LyallVikram Lyall More articles by this author , Michael GoltzmanMichael Goltzman More articles by this author , Stuart KeslerStuart Kesler More articles by this author , and Benjamin RistauBenjamin Ristau More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephron sparing surgery of horseshoe kidney masses can be technically challenging due to a variety of anatomic variations, including reduced mobility of the fused kidney and the presence of aberrant vessels. Near-Infrared Fluorescence Imaging (NIRF) is a technique utilized during robotic surgery in which indocyanine green (ICG) contrast provides differential fluorescence in normal renal parenchyma and vessels compared to tumor tissue. Identification of the intrarenal vasculature and perfusion ultimately facilitates selective arterial clamping. We present two cases of robotic assisted laparoscopic heminephrectomy (RALHN) utilizing ICG for RCC in HKs. METHODS: Two patients with suspected renal cell carcinoma of a HK underwent RALHN. Patients were risk stratified using the RENAL Nephrometry score. ICG-guided NIRF was utilized in each case to identify aberrant anatomy, visualize tumor from healthy tissue, and transect the isthmus with minimal blood loss. RESULTS: Both patients had no radiographic evidence of pre-operative metastasis and were of intermediate/high risk (RENAL Nephrometry score 10ph, and 8ph) (Figure 1a-b). Multiple renal arteries including an aberrant branch to the isthmus were identified in one patient (Figure 1c). Tumor was successfully excised with negative margins using ICG-related NIRF displaying differential fluorescence (Figure 2a-b). There was minimal blood loss (500 cc, 150 cc). Transection of the isthmus was completed in two different fashions: monopolar cautery and 60 Echelon stapler. CONCLUSIONS: This is the first report of ICG-guided NIRF utilized in RALHN in HKs. Despite a minimally invasive approach, aberrant anatomy was easily identified, and the isthmus was separated from the tumor without appreciable blood loss. This small case series highlights the expanding role of ICG in urologic surgery, particularly in HKs when there are unique anatomic considerations. Source of Funding: No funding © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e294-e295 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vikram Lyall More articles by this author Michael Goltzman More articles by this author Stuart Kesler More articles by this author Benjamin Ristau More articles by this author Expand All Advertisement Loading ...

Usefulness of intraoperative contrast-enhanced color Doppler ultrasonography for selective renal artery clamping in robot-assisted partial nephrectomy.

Usefulness of intraoperative contrast-enhanced color Doppler ultrasonography for selective renal artery clamping in robot-assisted partial nephrectomy.

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

Robotic anatomical resection of liver segment 4 with glissonian approach and selective hepatic artery clamping

How I divide the liver parenchyma - robotic technique

Presenter: Marcel Autran Machado MD | Nove de Julho Hospital Background: Surgical resection is the only curative modality of treatment in patients with primary and secondary liver resections. However, blood loss remains a significant factor affecting prognosis. The development of bloodless techniques to facilitate surgical resection of liver tumors has stimulated HPB surgeons. Methods: The authors have devised a technique to perform a bloodless liver transection without any suture or ligature on the raw surface of the liver and without the need of any expensive and/or sophisticated devices during robotic liver resections. The bipolar forceps with saline irrigation under selective hepatic artery clamping is the key to achieve a bloodless raw liver area. Some video extracts are included to better illustrate the technique and its ability to control major hepatic veins and portal pedicles. Results: We have successfully used this technique in our robotic liver resection since 2018. It may preclude the use of staplers thus reducing operating costs. Conclusion: The present technique of robotic liver transection is safe and bloodless.

Video 10 - Selective Segmental Renal Artery Clamping During Retro and Trans-Peritoneal Robotic-Assisted Laparoscopic Partial Nephrectomy for Hilar Tumours: Technique and Outcome

Video 10 - Selective Segmental Renal Artery Clamping During Retro and Trans-Peritoneal Robotic-Assisted Laparoscopic Partial Nephrectomy for Hilar Tumours: Technique and Outcome

Selective clamping during robot-assisted partial nephrectomy in patients with a solitary kidney: is it safe and does it help?

To obtain the most accurate assessment of the risks and benefits of selective clamping in robot-assisted partial nephrectomy (RAPN) we evaluated outcomes of this technique vs those of full clamping in patients with a solitary kidney undergoing RAPN. Data from institutional review board-approved retrospective and prospective databases from 2006 to 2019 at multiple institutions with sharing agreements were evaluated. Patients with a solitary kidney were identified and stratified based on whether selective or full renal artery clamping was performed. Both groups were analysed with regard to demographics, risk factors, intra-operative complications, and postoperative outcomes using chi-squared tests, Fisher's exact tests, t-tests and Mann-Whitney U-tests. Our initial cohort consisted of 4112 patients, of whom 72 had undergone RAPN in a solitary kidney (51 with full clamping and 21 with selective clamping). There were no significant differences in demographics, tumour size, baseline estimated glomerular filtration rate (eGFR), or warm ischaemia time (WIT) between the groups (Table 1). Intra-operative outcomes, including estimated blood loss, operating time, and intra-operative complications were similar in the two groups. Short- and long-term postoperative percentage change in eGFR, frequency of acute kidney injury (AKI), and frequency of de novo chronic kidney disease (CKD) were also not significantly different between the two techniques. In a large cohort of patients with solitary kidney undergoing RAPN, selective clamping resulted in similar intra-operative and postoperative outcomes compared to full clamping and conferred no additional risk of harm. However, selective clamping did not appear to provide any functional advantage over full clamping as there was no difference observed in the frequency of AKI, CKD or change in eGFR. Short WIT in both groups (<15min) may have prevented identification of benefits in the selective clamping group; a similar study analysing cases with longer WIT may elucidate any beneficial effects of selective clamping.

AB021. Selective segmental renal artery clamping during retro and trans-peritoneal robotic-assisted laparoscopic partial nephrectomy for hilar tumours: technique and outcome

AB021. Selective segmental renal artery clamping during retro and trans-peritoneal robotic-assisted laparoscopic partial nephrectomy for hilar tumours: technique and outcome

Robotic partial nephrectomy: The current status

Introduction:Since its introduction, robotic partial nephrectomy (RPN) has become increasingly popular, in part as a result of several advances in technique. The purpose of this paper is to review these techniques as well as the perioperative, functional, and oncologic outcomes after RPN and compare these outcomes to those after laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN).Methods:A literature review was performed to identify papers and meta-analyses that compared outcomes after RPN to OPN or LPN. All meta-analyses were included in this review.Results:Technical advances that have contributed to improved outcomes after RPN include the first-assistant sparing technique, the sliding clip technique, early unclamping, and selective arterial clamping. All five meta-analyses that compared LPN to RPN found that RPN was associated with a shorter warm ischemia time (WIT), but that there were no differences in estimated blood loss (EBL) or operative times. Those meta-analyses that compared intraoperative and postoperative complications, conversion to open or radical nephrectomy, length of stay (LOS), and postoperative estimated glomerular filtration rate (eGFR) either found no difference or favored RPN. Four meta-analyses compared RPN to OPN. All four found that EBL, LOS, and postoperative complications favor RPN. There were no significant differences in intraoperative complications, conversion to radical nephrectomy, or positive surgical margin rates. One meta-analysis found that eGFR was better after RPN. Operative time and WIT generally favored OPN.Conclusions:Several techniques have been described to improve outcomes after RPN. We believe that the literature shows that RPN is as good if not better than both LPN and OPN and has become the preferred surgical approach.

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n=375, 81.2%), SAC (n=48, 10.4%) or OC (n=39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24months, were included in the model for analysis. The median follow-up was 12.0months (interquartile range 6.7-16.5; range 3.0-24.0months). In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β=-1.20, 95% confidence interval [CI] -5.45, 3.06; P=0.582) and OC and MAC RPN (β=-1.57, 95% CI -5.21, 2.08; P=0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17min for MAC and 15min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

Comparative study on the curative effect of laparoscopic nephron sparing surgery and renal functions under selective segmental renal artery clamping and main renal artery clamping.

Objective:To discuss the clinical effect and safety evaluation of laparoscopic nephron sparing surgery (LNSS) under selective segmental renal artery clamping (SSRAC) and main renal artery clamping (MRAC).Methods:Eighty-four patients with T1 localized renal tumors who were admitted and treated from October 2017 to October 2018 were retrospectively analyzed, and they were classified into the S group (42 patients) and M group (42 patients). The patients in the S group received LNSS under SSRAC, while the patients in the M group received LNSS under MRAC. The duration of the operation, amount of intraoperative blood loss, intraoperative warm ischemia time, duration of postoperative hospital stay and positive rate of incisal edge; the serum creatinine and blood urea nitrogen values before and after the operation; and the occurrence rates of intraoperative and postoperative complications were compared.Results:All operations were completed smoothly. No patients had a positive incisal edge, and no patients were converted to MRAC during the operation. The duration of the operation and the amount of intraoperative blood loss increased in the S group compared with the M group. The differences were statistically significant (P <0.05). The differences in the intraoperative warm ischemia time, postoperative drainage and duration of postoperative hospital stay in both groups had no statistical significance (P >0.05). The differences in serum creatinine (SCr) and blood urea nitrogen (BUN) in both groups before the operation had no statistical significance (P >0.05). The SCr and BUN levels significantly increased 1 d and 1 m after the operation. The SCr and BUN levels 1 d and 1 m after the operation were significantly lower in the S group than in the M group, and the differences were statistically significant (P <0.05). The differences in the occurrence rates of intraoperative and postoperative complications in both groups had no statistical significance (P >0.05).Conclusion:SSRAC is a new renal artery clamping technology, and its curative effect on LNSS patients is significant. In addition, SSRAC has high safety and little influence on renal functions.