Near‐infrared fluorescence imaging to facilitate super‐selective arterial clamping during zero‐ischaemia robotic partial nephrectomy

Abstract

What's known on the subject? and What does the study add?• There is concern that warm ischaemia time during partial nephrectomy may have an adverse impact on postoperative renal function. As a result, there is increased interest in developing a safe and effective method for performing non-ischaemic partial nephrectomy. Several novel approaches have recently been described.• We present our initial experience performing zero-ischaemia partial nephrectomy using near-infrared fluorescence imaging to facilitate super-selective arterial clamping. We report the operative and early postoperative outcomes from such cases as compared with a matched cohort of patients undergoing traditional partial nephrectomy with clamping of the main renal artery. We show that this technique is both safe and effective and may lead to improved renal preservation at short-term follow-up. Objective• To describe a novel technique of eliminating renal ischaemia during robotic partial nephrectomy (RPN) using near-infrared fluorescence (NIRF) imaging. Patients and Methods• Over an 8-month period (March 2011 to November 2011), 34 patients were considered for zero-ischaemia RPN using the da Vinci NIRF system. • Targeted tertiary/higher-order tumour-specific branches were controlled with robotic bulldog(s) or neurosurgical aneurysm micro-bulldog(s). Indocyanine green dye was given, and NIRF imaging used to confirm super-selective ischaemia, defined as darkened tumour/peri-tumour area with green fluorescence of remaining kidney.• Matched pair analysis was performed by matching each patient undergoing zero-ischaemia RPN (n = 27) to a previous conventional RPN (n = 27) performed by the same surgeon. Results• Of 34 patients, 27 (79.4%) underwent successful zero-ischaemia RPN; seven (20.6%) required conversion to main renal artery clamping (ischaemia time <30 min) for the following reasons: persistent tumour fluorescence after clamping indicating inadequate tumoral devascularization (n = 5), and parenchymal bleeding during RPN (n = 2).• Matched-pair analysis showed comparable outcomes between cohorts, except for longer operating time (256 vs 212 min, P = 0.02) and superior kidney function (reduction of estimated glomerular filtration rate (-1.8% vs -14.9%, P = 0.03) in the zero-ischaemia cohort. All surgical margins were negative. Conclusions• In this pilot study, we show that zero-ischaemia RPN with NIRF is a safe alternative to conventional RPN with main renal artery clamping.• Eliminating global ischaemia may improve functional outcomes at short-term follow-up.

Robotic sequential right adrenalectomy and zero ischemia left partial nephrectomy in a patient with synchronous pheochromocytoma and renal cell carcinoma

“…Thereafter, indocyanine green dye was given, and NIRF imaging was used to confirm superselective ischemia, defined as a darkened tumor/peritumor area with green fluorescence in the remaining kidney. [21] This technique was suggested to be a safe alternative to conventional RPN with main renal artery clamping that eliminates global renal ischemia. Therefore, with the development of new technological advancements, zero ischemia RPN may be performed more frequently in suitable and selected cases.…”

“…Recently, a novel technique of eliminating renal ischemia during RPN using near-infrared fluorescence (NIRF) imaging was described. [21] Targeted tertiary/higher-order tumor-specific arterial branches were controlled with robotic bulldog(s) or neurosurgical aneurysm micro-bulldog(s). Thereafter, indocyanine green dye was given, and NIRF imaging was used to confirm superselective ischemia, defined as a darkened tumor/peritumor area with green fluorescence in the remaining kidney.…”

Advances in fluorescent-image guided surgery

“…As seen with other surgeries, ICG alerted surgeons to abnormal vascular anatomy, helping them avoid unintended injuries that would be otherwise difficult to predict (112,113). This technology could help surgeons spare larger portions of the kidney in partial nephrectomy and reduce postoperative complications, blood loss, and metastasis (113,114). Similarly, ICG was used in robotic partial adrenalectomy to differentiate between adrenal mass and normal parenchyma, helping to spare as much of the adrenal gland as possible while completely excising the tumor (115,116).…”

Near-infrared imaging of brain tumors using the Tumor Paint BLZ-100 to achieve near-complete resection of brain tumors

“…32 There are multiple imaging systems that have been developed by both academic and industrial groups. 5,8,9,17,19,21,22,24,25,31,33,38,39 There are separate systems for open surgeries, laparoscopic surgeries, and robot-assisted surgeries that vary based on specific challenges. Some of the important criteria for developing a new imaging system are based on concentration of the fluorophores, type of tissue due to varying tissue penetration depths, ergonomics, and cost.…”