Selective Renal Parenchymal Clamping in Robot-Assisted Laparoscopic Partial Nephrectomy: A Multi-Institutional Experience

Viprakasit, Davis P.; Derweesh, Ithaar; Wong, Carson; Su, Li Ming; Stroup, Sean P.; Bazzi, Wassim M.; Strom, Kurt H.; Herrell, S. Duke

doi:10.1089/end.2010.0667

Cited by 21 publications

(15 citation statements)

References 19 publications

(30 reference statements)

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“…Studies revealed an increase in estimated blood loss for this approach without an increase in transfusion rates [78], whereas others seemed to show increased transfusion rates [77]. Clampless minimally invasive PN may be aided by prior superselective embolization of tumor-specific arteries [79,80], prior radiofrequency ablation [81], and parenchymal clamping [82] in select cases. In minimally invasive PN for selected tumors, a bolster can be omitted [83].…”

Section: Evidence Synthesismentioning

confidence: 99%

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

et al. 2015

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Context A detailed understanding of renal surgical anatomy is necessary to optimize preoperative planning and operative technique and provide a basis for improved outcomes. Objective To evaluate the literature regarding pertinent surgical anatomy of the kidney and related structures, nephrometry scoring systems, and current surgical strategies for partial nephrectomy (PN). Evidence acquisition A literature review was conducted. Evidence synthesis Surgical renal anatomy fundamentally impacts PN surgery. The renal artery divides into anterior and posterior divisions, from which approximately five segmental terminal arteries originate. The renal veins are not terminal. Variations in the vascular and lymphatic channels are common; thus, concurrent lymphadenectomy is not routinely indicated during PN for cT1 renal masses in the setting of clinically negative lymph nodes. Renal-protocol contrast-enhanced computed tomography or magnetic resonance imaging is used for standard imaging. Anatomy-based nephrometry scoring systems allow standardized academic reporting of tumor characteristics and predict PN outcomes (complications, remnant function, possibly histology). Anatomy-based novel surgical approaches may reduce ischemic time during PN; these include early unclamping, segmental clamping, tumor-specific clamping (zero ischemia), and unclamped PN. Cancer cure after PN relies on complete resection, which can be achieved by thin margins. Post-PN renal function is impacted by kidney quality, remnant quantity, and ischemia type and duration. Conclusions Surgical renal anatomy underpins imaging, nephrometry scoring systems, and vascular control techniques that reduce global renal ischemia and may impact post-PN function. A contemporary ideal PN excises the tumor with a thin negative margin, delicately secures the tumor bed to maximize vascularized remnant parenchyma, and minimizes global ischemia to the renal remnant with minimal complications. Patient summary In this report we review renal surgical anatomy. Renal mass imaging allows detailed delineation of the anatomy and vasculature and permits nephrometry scoring, and thus precise, patient-specific surgical planning. Novel off-clamp techniques have been developed that may lead to improved outcomes.

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Section: Evidence Synthesismentioning

confidence: 99%

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

et al. 2015

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“…22,23 As reported by others, use of the parenchymal clamp is best suited for exophytic and peripheral tumors to allow adequate compression of the parenchyma and avoid overlap with the hilum. 15–17 In our experience, the upper pole location might limit the placement of the clamp because of potential collisions with the robotic arms. Although the ideal tumor location is believed to be the lower pole, with aggressive mobilization of the kidney from the surrounding fat, the clamp might be used to help rotate the kidney to allow usage for lateral and posterior tumors as well.…”

Section: Commentmentioning

confidence: 99%

“…Immediate postoperative renal function was similar to baseline. A multi-institutional study by Viprakasit et al 17 reported outcomes after RALPN from 4 centers using the parenchymal clamp. Overall, 20 of 88 (23%) patients undergoing RALPN were treated with the parenchymal clamp with successful placement in 17 (85%).…”

Section: Commentmentioning

confidence: 99%

“…As other investigators have noted, central and hilar tumors would not be feasible with this technique, but tumor size is not a limitation if the tumor is in an ideally located position. 15–17 …”

Section: Commentmentioning

confidence: 99%

“…The clamp can be placed around the kidney to isolate peripherally located masses and create regional ischemia. Single 15,16 and multi-institutional 17 series have reported feasibility of the parenchymal clamp in select patients undergoing RALPN. Proposed advantages of the parenchymal clamp include sparing most kidneys from ischemia, allowing longer time for excision and reconstruction, and requiring less hilar dissection.…”

mentioning

confidence: 99%

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Comparison of Selective Parenchymal Clamping to Hilar Clamping During Robotic-assisted Laparoscopic Partial Nephrectomy

Hsi

Macleod

Gore

et al. 2014

Urology

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OBJECTIVE To compare perioperative outcomes after robotic-assisted laparoscopic partial nephrectomy (RALPN) with hilar clamping vs parenchymal clamping. METHODS A retrospective, single-institution review of the patients undergoing RALPN with hilar or parenchymal clamping was performed. Associations between perioperative factors and clinicopathologic outcomes were determined using the t test, Fisher’s exact test, and multivariate linear regression. RESULTS In 51 patients undergoing RALPN, 36 (71%) and 15 (29%) were performed with hilar and parenchymal clamping, respectively. Median tumor diameter was 2.8 cm for both groups (range, 1.1–6.1; P =.93). Tumor complexity by nephrometry score was mild (69% vs 80%), moderate (29% vs 20%), and high (2% vs 0%) in the respective groups (P =.65). Operative time was significantly shorter in the parenchymal clamp group (median 245 vs 320 minutes; P <.0001). There was no difference in blood loss and need for transfusion. On multivariate analysis, hilar clamping (P <.01), higher body mass index (P =.01), and higher complexity tumors (P =.02) were significantly associated with longer operative times. The parenchymal clamp group had better preservation of immediate postoperative glomerular filtration rate (GFR) from baseline to postoperative day 2 (median ΔGFR 0 vs −18 mL/min/1.73 m2, P =.02). These differences from baseline did not persist (median ΔGFR −6 vs −7 mL/min/1.73 m2, P =.35) at a median follow-up of 6.6 months. Final pathology determination of malignancy (P =.51) and positive margin rates (P =.26) were similar in both groups. CONCLUSION Compared with hilar clamping, selective regional ischemia with the parenchymal clamp for mild-moderately complex tumors is feasible and safe during RALPN. Parenchymal clamping is associated with enhanced immediate preservation of GFR and shorter operative times.

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Console-integrated real-time three-dimensional image overlay navigation for robot-assisted partial nephrectomy with selective arterial clamping: early single-centre experience with 17 cases

Furukawa

Tanaka

Sugimoto

et al. 2014

Int J Med Robotics Comput Assist Surg

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Selective Renal Parenchymal Clamping in Robot-Assisted Laparoscopic Partial Nephrectomy: A Multi-Institutional Experience

Cited by 21 publications

References 19 publications

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

A Literature Review of Renal Surgical Anatomy and Surgical Strategies for Partial Nephrectomy

Comparison of Selective Parenchymal Clamping to Hilar Clamping During Robotic-assisted Laparoscopic Partial Nephrectomy

Console-integrated real-time three-dimensional image overlay navigation for robot-assisted partial nephrectomy with selective arterial clamping: early single-centre experience with 17 cases

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