Alternative techniques to reduce warm ischemia time in laparoscopic partial nephrectomy

Abstract

_______________________________________________________________________________Purpose: Demonstrate two alternatives that permit a warm ischemia time reduction during laparoscopic partial nephrectomy. Materials and Methods: In this video, two cases of intermediate complexity renal tumors according to the RENAL nephrometry renal scoring system illustrating the techniques and our preliminary experience: a 65 year old man with a 4 cm right, posterior renal tumor. This patient underwent an early unclamping and parenchymal suturing using a greek bar continuous suture with hem-o-lock clips attached to the respective extremities of the suture; The second patient is a 49 year old man with a 3 cm renal tumor. The technique utilized was no clamping resection following the ABC Medical School technique: dissection of renal hilum for eventual clamping if necessary, a frontal 360 degrees visualization of tumor limits, pneumoperitoneum pressure elevated to 25mmHg during tumor resection, spiral excavation of normal parenchyma around the tumor and resection with negative margins. Results: We previously performed 15 cases utilizing the early unclamping technique. The mean clamp time was 15 minutes with a mean blood loss of 285 mL. Only 1 patient had focal positive surgical margins, without recurrence demonstrated at 30 months. Fifteen partial nephrectomies were previously performed with on demand clamping. In 3 cases, clamping was necessary with a mean ischemia time of 11 minutes. The mean blood loss was 390 mL and 2 cases required a perioperative blood transfusion. One case presented with a positive focal margin without recurrence demonstrated at 24 months of follow-up. Renal function was preserved in all cases regardless of the technique applied. Conclusion: Warm ischemia time can be reduced and kidney function can be preserved during laparoscopic nephrectomy if either early unclamping or on demand clamping are selectively applied. ARTICLE INFO

Recommendations and optimal approaches to robotic-assisted partial nephrectomy: A consensus of Brazilian experts

“…Several ischemic techniques have been described and used throughout the evolution of partial nephrectomy: cold ischemia, WIT with complete arterial clamping (renal artery trunk), selective ischemia, early de-clamping, and zero ischemia (no clamping) (35,36).…”

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“…When performing a laparoscopic partial nephrectomy, it is almost always necessary to keep the kidney in warm ischemia, depending on size and location of the tumor ( 3 , 4 ). There is a great discussion over the maximum warm ischemia time, and most authors consider 30 minutes as the upper limit ( 3 , 5 ).…”