“Zero Ischemia” Partial Nephrectomy: Novel Laparoscopic and Robotic Technique

Abstract: Background: Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. Objective: Describe a novel technique of “zero ischemia” laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. Design, setting, and participants: Data were prospectively collected into an institutional review board–approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n =12), RAPN (n =3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n =9; 60%), hilar (n =1), in solitary kidney (n =1), in patients with chronic kidney disease grade 3 or greater (n =3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan–Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. Measurements: Intraoperative and early postoperative data were collected prospectively. Results and limitations: All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5cm (range: 1–4); operative time was 3h (range: 1.3–6); blood loss was 150ml (range: 20–400); and hospital stay was 3 d (range: 2–19). Nadir mean arterial pressure ranged from 52–65mm Hg (median: 60), typically for 1–5min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n =5) included urine retention (n =1), septicemia from presumed prostatitis (n =1), atrial fibrillation (n =1), urine leak (n =2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9mg/dl and 0.95mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. Conclusions: A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging. [Copyright &y& Elsevier]