Selective Versus Nonselective Arterial Clamping During Laparoscopic Partial Nephrectomy: Impact upon Renal Function in the Setting of a Solitary Kidney in a Porcine Model

Abstract

Diaz, Dilmer L.; Maxwell, Keegan L.; Badwan, Khalid H.; Talcott, Michael R.; Liapis, Helen; Cabello, Jose M.; Venkatesh, Ramakrishna; and Figenshau, Robert S., ,"Selective versus nonselective arterial clamping during laparoscopic partial nephrectomy: Impact upon renal function in the setting of a solitary kidney in a porcine model." Journal of Endourology.23,7. 1127Endourology.23,7. -1133Endourology.23,7. . (2009 Introduction: Laparoscopic partial nephrectomy has emerged as a standard of care for small renal masses. Nevertheless, there remains concern over the potential for irreversible insult to the kidney as a result of exposure to warm ischemia. We aim to investigate the utility of selective segmental arterial clamping as a means to reduce the potential for ischemic damage to a solitary kidney during laparoscopic partial nephrectomy utilizing a porcine model. Materials and Methods: A total of 20 domestic swine were randomized into four equal groups. Each subject underwent laparoscopic radical nephrectomy to create the condition of a solitary kidney. On the contralateral side, a laparoscopic lower pole partial nephrectomy was performed, employing either selective or nonselective vascular clamping for either 60 or 90 minutes. Postoperatively, clinical status and serial serum studies were closely monitored for 1 week.Results: There were no intraoperative complications. The 90-minute nonselective clamping produced devastating effects, resulting in rapid deterioration into florid renal failure within 72 hours. The 60-minute nonselective clamping group experienced modest but significant rises in both blood urea nitrogen and creatinine. Both 60-and 90-minute selective clamping groups performed well, with no significant rises in creatinine over a 7-day period, and no instances of renal failure. Conclusions: Selective arterial clamping is a safe and feasible means of vascular control during laparoscopic partial nephrectomy. In the porcine model, selective clamping appears to improve functional outcomes during prolonged periods of warm ischemic insult. Prospective evaluation of the technique in humans is necessary to determine if selective arterial control confers long-term functional benefits in patients with limited renal reserve.

Off-Clamp Robot-Assisted Partial Nephrectomy: Initial Washington University Experience

“…Viprakasit and colleagues 26 described successful use of this technique in three patients undergoing RAPN. 26 We previously reported improved renal functional outcomes with segmental rather than complete hilar clamping in a porcine model 27 and demonstrated the safety and feasibility of this technique in humans. 28 More recently, some surgeons have performed PN without any clamping of the renal hilum and have suggested that off-clamp PN can be safely performed in carefully selected patients.…”

“…Of note, this technique represents an evolution in our efforts to minimize WIT, building on our previous experience with segmental arterial clamping. 27,28 In the short-term, a minimal and statistically insignificant decline in renal function was seen after off-clamp RAPN. The mean EBL (210 mL) and operative time (143 min) were clinically appropriate, and all surgical margins were negative for tumor.…”

Organ-preserving laparoscopic surgeries for renal cancer with the use of segment-by-segment ischemia

“…Хорошей альтернативой традиционным методам противо-ишемической защиты является селективное вы-ключение кровотока в опухолевом узле или в содер-жащем его сегменте почки. Эффективность такого подхода при лапароскопических операциях была продемонстрирована в эксперименте на животных [15]. В последнее время появились первые, но весь-ма обнадеживающие сообщения об использовании локальной ишемии при лапароскопической резек-ции почки в клинике [7].…”

Current Status of Robot-Assisted Laparoscopic Partial Nephrectomy

“…Selective arterial clamping is a recent technique that had undergone evaluation in porcine models [24]. In this technique, only the segmental artery supplying the tumour was clamped.…”