JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 11, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2014.0212
Experience of Laparoscopic Partial Nephrectomy Using a Kidney Grasper in Selective Cases Fumiya Hongo, MD, PhD,1 Akihiro Kawauchi, MD, PhD,2 Yoshizo Itoh, MD, PhD,3 Hidetaka Fujii, MD,1 Yasuyuki Naitoh, MD, PhD,1 Terukazu Nakamura, MD, PhD,1 Yoshio Naya, MD, PhD,1 Kazumi Kamoi, MD, PhD,1 Koji Okihara, MD, PhD,1 and Tsuneharu Miki, MD, PhD1
Abstract
Objective: To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney. Materials and Methods: The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper. Results: Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23–25 minutes), and the mean blood loss was 110 mL (range, 20–260 mL). Conclusions: This procedure may be a useful option in ischemia for partial nephrectomy.
Background
R
adical nephrectomy was previously considered for the surgical treatment of small renal cancer, but the importance of functional conservation has recently been reported, which has widely promoted the recognition of partial nephrectomy, and the procedure is recommended in the recent guidelines.1–3 Minimally invasive laparoscopic surgery has also spread, and laparoscopic partial nephrectomy is now performed. Although laparoscopic partial nephrectomy is minimally invasive, ischemia of the renal artery or renal artery and vein is applied to control bleeding in partial resection. On the other hand, to conserve the renal function, it is important to shorten the duration of ischemia. Operators are required to have advanced techniques to perform tumor resection and suturing during a limited ischemia time under laparoscopic conditions. If ischemia can be limited to a localized region, ischemia of the main renal artery is unnecessary, which may facilitate conservation of the renal function in a secured condition. The 1 2 3
laparoscopic Simon clamp (Aesculap AG, Tuttlingen, Germany) is a newly developed laparoscopic clamp with a standard locking handle and an open jaw diameter of 70 mm (Fig. 1).4 Materials and Methods
The subjects were 5 patients with small renal cell carcinoma. There were 2 male and 3 female patients, at a median age of 54 years (range, 46–63 years). The median height was 160 cm (range, 152–167 cm), and the median body mass index was 23.6 kg/m2 (range, 19–26.2 kg/m2). The affected side was right in 4 patients and left in 1 patient, and the median tumor diameter was 15 mm (range, 11–25 mm). Mass location was upper in 1 patient and lower in 4 patients. The median RENAL nephrometry score was 5 (range, 4–5). Their outcomes were compared with those of 94 patients with a RENAL nephrometry score of 4–6 treated by laparoscopic partial nephrectomy with conventional hilum clamping between 2006 and 2013.
Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Department of Urology, Shiga University of Medical Science, Shiga, Japan. Department of Urology, Kyoto Second Red Cross Hospital, Kyoto, Japan.
795
796
FIG. 1. Simon renal pole clamp for selective renal clamping.
Procedure
After the administration of general anesthesia, the patient was fixed in the lateral decubitus position. A transperitoneal approach was used in all patients. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapid clamping with forceps. Laparoscopic ultrasonography at 5–10 MHz was used to identify the tumor location and surgical margins. The incision line, which was 5 mm from the tumor margin, was marked circumferentially on the renal capsule using electorocautery monopolar scissors. After the intravenous administration of 25 mg of mannitol, the laparoscopic Simon clamp was introduced through the 12-mm port to allow for closure and placed adequately along the tumor margin.
HONGO ET AL.
Once the Simon clamp was closed with self-locking, it allowed rotation of the kidney for optimal tumor visualization and supported excision of the tumor. After tumor resection using scissor forceps, hemostasis was applied to the resected stump with bipolar grasping forceps, followed by suture of the resected surface. The lesion was filled with rolled Surgicel bolster (Ethicon, Inc., Somerville, NJ) and then sutured in Cases 2 and 3. Resection of the tumor in regional ischemia with cold scissors in a bloodless field in Case 3 is shown in Figure 2. Computed tomography revealed a 15-mm tumor located in the lower pole of the left kidney (Fig. 2A for transverse and B for sagittal). The RENAL nephrometry score was 5. The kidney was dissected circumferentially and fully mobilized by the transperitoneal approach. The kidney grasper was introduced through the 12-mm port. The tumor with its margin was kept in regional ischemia by the kidney grasper (Fig. 2C). The tumor was dissected with cold scissors (Fig. 2D and E). After complete excision, the tumor bed was coagulated by the bipolar grasper and sutured (Fig. 2F). Rolled Surgicel bolster was then applied to the tumor bed, and parenchymal sutures were added. Results
This procedure was used in 5 patients between June 2011 and August 2012, and surgery could be completed in 4 patients. In the first case, control of bleeding was considered difficult during tumor resection under partial ischemia, and the procedure was switched to renal artery clamping using bulldog forceps. The blood loss was 150 mL. The results of surgery attempting the use of a kidney grasper are summarized in Table 1. The median total operative time was 220 minutes (range, 175–239 minutes), and the mean clamping time was 23.6 minutes (range, 23–26
FIG. 2. Resection of the tumor in regional ischemia with cold scissors in a bloodless field in Case 3. Computed tomography revealed a 15-mm tumor located in the lower pole of the left kidney: (A) transverse and (B) sagittal. (C) The tumor with margin was subjected to regional ischemia with the kidney grasper. (D and E) The tumor was dissected with cold scissors. (F) The tumor bed was coagulated with the bipolar grasper and sutured.
PARTIAL NEPHRECTOMY USING A KIDNEY GRASPER
797
Table 1. Perioperative Characteristics of Patients Undergoing Partial Nephrectomy with Regional Ischemia and Conventional Clamping Selective clamp Total operative time (minutes) Clamping time (minutes) Blood loss (mL) Serum creatinine (mg/dL) Preoperative Postoperative % increase of serum creatinine
Conventional clamp
220 (175–239) 24.4 (23–26) 50 (10–260)
235 (121–500) 50 (21–103) 100 (5–2500)
0.6 (0.5–0.81) 0.69 (0.52–0.86) 15 ( - 13 to 25)
0.78 (0.42–2.47) 0.85 (0.58–3.47) 9.51 ( - 20 to 132)
P value .3658 < .001 .5154 .1736 .2873 .6554
Data are median values (range).
minutes). The median blood loss was 50 mL (range, 10– 260 mL), and no blood transfusion was performed. No opening of the renal pelvis was noted in any patient. No postoperative complication occurred. The histopathological diagnosis was renal cell carcinoma clear cell, and the resected stump was negative in all patients. The median serum creatinine level was 0.6 (range, 0.5–0.81) mg/dL before surgery and 0.69 (range, 0.52–0.86) mg/dL 6 months after surgery. The median estimated glomerular filtration rate was 85.01 (range, 76–97.4) mL/minute/1.73 m2 before surgery and 79.76 (range, 68.4–90) mL/minute/1.73 m2 6 months after surgery. There were no Clavien–Dindo complications at the 90-day follow-up. At a mean follow-up of 17 months no recurrence was noted. Peri- and postoperative parameters of clamping were compared with those of conventional clamping in our institute (Table 1). No significant differences were observed in total operative time (220 minutes versus 235 minutes), median blood loss (50 mL versus 100 mL), and serum creatinine percentage change (serum creatinine level preoperatively versus 6 months after surgery, 15% versus 9.51%). Discussion
The concept of trifecta outcomes during robot/laparoscopic partial nephrectomy, with the three key outcomes of a negative cancer margin, minimal function decrease, and no urological complications, has been realized.5 To minimize reduction of the renal function, it may be necessary to minimize the warm ischemia time, for which cooling, a nonischemic method, or limited range of ischemia is considered. Sufficient cooling of the clamped renal artery and vein may be useful. This procedure is widely used in open surgery and may be applicable for laparoscopic surgery using a retroperitoneal approach,6 but effective cooling is technically difficult for surgery through a peritoneal approach. Thus, this procedure may be not useful. Partial ischemia procedures using various energy devices have been investigated, including an ultrasonically activated bending scalpel,7 water-jet dissector,8 diode laser,9 floating-ball radiofrequency dissector,10 microwaves,11 and radiofrequency coagulation.12 These are very useful for intraoperative hemostasis, and bleeding may be controlled with them. However, the margin cannot be readily decided because differentiation between normal renal tissue and the tumor is difficult. Thus, heat damage to the surrounding tissue, such as arteries, veins, and the calix, is of concern. Actually, unex-
pected collateral thermal damage to the surrounding structures, especially the collecting system, may cause urinoma, pelvicalyceal stenosis, and renal arteriovenous fistula.11,13,14 Because these complications have been reported, the indication may be limited to small protruding tumors. The main problem in partial nephrectomy under ischemia is that accurate resection and suture have to be performed within a limited time, placing mental pressure on operators. With an open jaw diameter of 70 mm, the Simon clamp is novel in that it has a standard ratchet handle that can be locked into place, thereby preventing clamp sliding, while curved jaws evenly distribute a constant and uniform pressure.4 As previously reported, partial ischemia using a kidney grasper requires no skilled laparoscopic technique, while ischemic damage of renal nephrons can be minimized, which may be the main advantage.15,16 For solitary kidney cases, damage to the renal function by surgery is a more serious concern, and it has been stated that partial ischemia is more appropriate than the method of applying complete ischemia to the hilum of the kidney.17 We think that the applicability of partial ischemia using this procedure should be judged in sufficient consideration of the tumor location and diameter. In addition, reconsideration of the positioning of an insertion port may also be necessary. However, application may be difficult depending on the tumor location, and tumors located in the superior or inferior pole (i.e., 25-mm or smaller protruding tumors located at the superior or inferior pole) may be favorable indications. This procedure may be a useful option in ischemia for partial nephrectomy. In our experiences, the procedure was switched to arterial ischemia in one of the 5 patients. Because the patient was the first case undergoing this procedure, we switched to arterial ischemia in the early phase, but this was considered sufficiently achievable in a later investigation. Parenchymal regional ischemia has been attempted using other methods, and the utility was reported. Previously reported methods of laparoscopic regional ischemia have ranged from a loop tourniquet or bands to commonly used vascular clamps. Parenchymal regional ischemia has been used to avoid complete vascular occlusion during partial nephrectomy.18–21 Zero ischemia using a clip for neurosurgery has been reported.22 There has been no report from other institutions, and this procedure may be used only at very limited facilities. This anatomical vascular microdissection of the artery first and then the tumor allows even complex tumors to be excised without hilar clamping. Compared with these, the Simon clamp may be easy to handle.
798 Conclusions
Selective renal parenchymal clamping during laparoscopic partial nephrectomy is feasible and an effective method to perform maximal nephron-sparing surgery without the need for warm ischemia for selective cases. Disclosure Statement
No competing financial interests exist. References
1. Motzer RJ, Agarwal N, Beard C, Bolger GB, Boston B, Carducci MA, Choueiri TK, Figlin RA, Fishman M, Hancock SL, Hudes GR, Jonasch E, Kessinger A, Kuzel TM, Lange PH, Levine EG, Margolin KA, Michaelson MD, Olencki T, Pili R, Redman BG, Robertson CN, Schwartz LH, Sheinfeld J, Wang J. NCCN clinical practice guidelines in oncology: Kidney cancer. J Natl Compr Canc Netw 2009;7:618–630. 2. Ljungberg B, Cowan NC, Hanbury DC, Hora M, Kuczyk MA, Merseburger AS, Patard JJ, Mulders PF, Sinescu IC; European Association of Urology Guideline Group. EAU guidelines on renal cell carcinoma: The 2010 update. Eur Urol 2010;58:398–406. 3. Fujioka T, Obara W; Committee for Establishment of the Clinical Practice Guidelines for the Management of Renal Cell Carcinoma; Japanese Urological Association. Evidence-based clinical practice guidelines for renal cell carcinoma (summary—JUA 2007 edition). Int J Urol 2009;16: 339–353. 4. Simon J, Bartsch G Jr, Finter F, Hautmann R, de Petriconi R. Laparoscopic partial nephrectomy with selective control of the renal parenchyma: Initial experience with a novel laparoscopic clamp. BJU Int 2009;103:805–808. 5. Hung AJ, Cai J, Simmons MN, Gill IS. ‘‘Trifecta’’ in partial nephrectomy. J Urol 2013;189:36–42. 6. Tatsugami K, Tanaka S, Ohtsubo S, Inokuchi J, Yokomizo A, Kuroiwa K, Song YH, Naito S. Causes of diminished renal function in the affected kidney after partial nephrectomy. BJU Int 2012;110:E357–E361. 7. Harmon WJ, Kavoussi LR, Bishoff JT. Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears. Urology 2000;56:754–759. 8. Moinzadeh A, Hasan W, Spaliviero M, Finelli A, Kilciler M, Magi-Galluzzi C, El Gabry E, Desai M, Kaouk J, Gill IS. Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model. J Urol 2005;174: 317–321. 9. Ogan K, Jacomides L, Saboorian H, Koeneman K, Li Y, Napper C, Hoopman J, Pearle MS, Cadeddu JA. Sutureless laparoscopic heminephrectomy using laser tissue soldering. J Endourol 2003;17:295–300. 10. Sundaram CP, Rehman J, Venkatesh R, Lee D, Rageb MM, Kibel A, Landman J. Hemostatic laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device without renal vascular control. Urology 2003;61: 906–909.
HONGO ET AL.
11. Terai A, Ito N, Yoshimura K, Ichioka K, Kamoto T, Arai Y, Ogawa O. Laparoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors: Usefulness and complications. Eur Urol 2004;45:744–748. 12. Zeltser IS, Moonat S, Park S, Anderson JK, Cadeddu JA. Intermediate-term prospective results of radiofrequencyassisted laparoscopic partial nephrectomy: A non-ischaemic coagulative technique. BJU Int 2008;101:36–38. 13. Janetschek G. Laparoscopic partial nephrectomy for RCC: How can we avoid ischemic damage of the renal parenchyma? Eur Urol 2007;52:1303–1305. 14. Bensalah K. Evaluation of costs and morbidity associated with laparoscopic radiofrequency ablation and laparoscopic partial nephrectomy for treating small renal tumours. BJU Int 2008;101:467–471. 15. Viprakasit DP, Altamar HO, Miller NL, Herrell SD. Selective renal parenchymal clamping in robotic partial nephrectomy: Initial experience. Urology 2010;76:750–753. 16. Viprakasit DP, Derweesh I, Wong C, Su LM, Stroup SP, Bazzi W, Strom KH, Herrell SD: Selective renal parenchymal clamping in robot-assisted laparoscopic partial nephrectomy: A multi-institutional experience. J Endourol 2011;25:1487–1491. 17. Nozaki T, Iida H, Morii A, Fujiuchi Y, Fuse H. Selective renal parenchymal clamping in retroperitoneal partial nephrectomy. J Laparoendosc Adv Surg Tech A 2012;22: 168–172. 18. Gill IS, Munch LC, Clayman RV, McRoberts JW, Nickless B, Roemer FD. A new renal tourniquet for open and laparoscopic partial nephrectomy. J Urol 1995;154:1113– 1116. 19. Toren P, Al-Essawi T, McLean A, Jain U. Use of a novel parenchymal clamp for laparoscopic and open partial nephrectomy. Can Urol Assoc J 2010;4:E133–E136. 20. Verhoest G, Manunta A, Bensalah K, Vincendeau S, Rioux-Leclercq N, Guille´ F, Patard JJ: Laparoscopic partial nephrectomy with clamping of the renal parenchyma: Initial experience. Eur Urol 2007;52:1340–1346. 21. Denardi F, Borges GM, Silva W Jr, Stopiglia RM, Ferreira U, Billis A, Netto NR Jr. Nephron-sparing surgery for renal tumours using selective renal parenchymal clamping. BJU Int 2005;96:1036–1039. 22. Gill IS, Patil MB, Abreu AL, Ng C, Cai J, Berger A, Eisenberg MS, Nakamoto M, Ukimura O, Goh AC, Thangathurai D, Aron M, Desai MM. Zero ischemia anatomical partial nephrectomy: A novel approach. J Urol 2012;187: 807–814.
Address correspondence to: Fumiya Hongo, MD, PhD Department of Urology Kyoto Prefectural University of Medicine 465 Kajii-cho Kamigyo-ku 602-8566, Kyoto Japan E-mail: [email protected]
Experience of Laparoscopic Partial Nephrectomy Using a Kidney Grasper in Selective Cases Fumiya Hongo, MD, PhD,1 Akihiro Kawauchi, MD, PhD,2 Yoshizo Itoh, MD, PhD,3 Hidetaka Fujii, MD,1 Yasuyuki Naitoh, MD, PhD,1 Terukazu Nakamura, MD, PhD,1 Yoshio Naya, MD, PhD,1 Kazumi Kamoi, MD, PhD,1 Koji Okihara, MD, PhD,1 and Tsuneharu Miki, MD, PhD1
Abstract
Objective: To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney. Materials and Methods: The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper. Results: Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23–25 minutes), and the mean blood loss was 110 mL (range, 20–260 mL). Conclusions: This procedure may be a useful option in ischemia for partial nephrectomy.
Background
R
adical nephrectomy was previously considered for the surgical treatment of small renal cancer, but the importance of functional conservation has recently been reported, which has widely promoted the recognition of partial nephrectomy, and the procedure is recommended in the recent guidelines.1–3 Minimally invasive laparoscopic surgery has also spread, and laparoscopic partial nephrectomy is now performed. Although laparoscopic partial nephrectomy is minimally invasive, ischemia of the renal artery or renal artery and vein is applied to control bleeding in partial resection. On the other hand, to conserve the renal function, it is important to shorten the duration of ischemia. Operators are required to have advanced techniques to perform tumor resection and suturing during a limited ischemia time under laparoscopic conditions. If ischemia can be limited to a localized region, ischemia of the main renal artery is unnecessary, which may facilitate conservation of the renal function in a secured condition. The 1 2 3
laparoscopic Simon clamp (Aesculap AG, Tuttlingen, Germany) is a newly developed laparoscopic clamp with a standard locking handle and an open jaw diameter of 70 mm (Fig. 1).4 Materials and Methods
The subjects were 5 patients with small renal cell carcinoma. There were 2 male and 3 female patients, at a median age of 54 years (range, 46–63 years). The median height was 160 cm (range, 152–167 cm), and the median body mass index was 23.6 kg/m2 (range, 19–26.2 kg/m2). The affected side was right in 4 patients and left in 1 patient, and the median tumor diameter was 15 mm (range, 11–25 mm). Mass location was upper in 1 patient and lower in 4 patients. The median RENAL nephrometry score was 5 (range, 4–5). Their outcomes were compared with those of 94 patients with a RENAL nephrometry score of 4–6 treated by laparoscopic partial nephrectomy with conventional hilum clamping between 2006 and 2013.
Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Department of Urology, Shiga University of Medical Science, Shiga, Japan. Department of Urology, Kyoto Second Red Cross Hospital, Kyoto, Japan.
795
796
FIG. 1. Simon renal pole clamp for selective renal clamping.
Procedure
After the administration of general anesthesia, the patient was fixed in the lateral decubitus position. A transperitoneal approach was used in all patients. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapid clamping with forceps. Laparoscopic ultrasonography at 5–10 MHz was used to identify the tumor location and surgical margins. The incision line, which was 5 mm from the tumor margin, was marked circumferentially on the renal capsule using electorocautery monopolar scissors. After the intravenous administration of 25 mg of mannitol, the laparoscopic Simon clamp was introduced through the 12-mm port to allow for closure and placed adequately along the tumor margin.
HONGO ET AL.
Once the Simon clamp was closed with self-locking, it allowed rotation of the kidney for optimal tumor visualization and supported excision of the tumor. After tumor resection using scissor forceps, hemostasis was applied to the resected stump with bipolar grasping forceps, followed by suture of the resected surface. The lesion was filled with rolled Surgicel bolster (Ethicon, Inc., Somerville, NJ) and then sutured in Cases 2 and 3. Resection of the tumor in regional ischemia with cold scissors in a bloodless field in Case 3 is shown in Figure 2. Computed tomography revealed a 15-mm tumor located in the lower pole of the left kidney (Fig. 2A for transverse and B for sagittal). The RENAL nephrometry score was 5. The kidney was dissected circumferentially and fully mobilized by the transperitoneal approach. The kidney grasper was introduced through the 12-mm port. The tumor with its margin was kept in regional ischemia by the kidney grasper (Fig. 2C). The tumor was dissected with cold scissors (Fig. 2D and E). After complete excision, the tumor bed was coagulated by the bipolar grasper and sutured (Fig. 2F). Rolled Surgicel bolster was then applied to the tumor bed, and parenchymal sutures were added. Results
This procedure was used in 5 patients between June 2011 and August 2012, and surgery could be completed in 4 patients. In the first case, control of bleeding was considered difficult during tumor resection under partial ischemia, and the procedure was switched to renal artery clamping using bulldog forceps. The blood loss was 150 mL. The results of surgery attempting the use of a kidney grasper are summarized in Table 1. The median total operative time was 220 minutes (range, 175–239 minutes), and the mean clamping time was 23.6 minutes (range, 23–26
FIG. 2. Resection of the tumor in regional ischemia with cold scissors in a bloodless field in Case 3. Computed tomography revealed a 15-mm tumor located in the lower pole of the left kidney: (A) transverse and (B) sagittal. (C) The tumor with margin was subjected to regional ischemia with the kidney grasper. (D and E) The tumor was dissected with cold scissors. (F) The tumor bed was coagulated with the bipolar grasper and sutured.
PARTIAL NEPHRECTOMY USING A KIDNEY GRASPER
797
Table 1. Perioperative Characteristics of Patients Undergoing Partial Nephrectomy with Regional Ischemia and Conventional Clamping Selective clamp Total operative time (minutes) Clamping time (minutes) Blood loss (mL) Serum creatinine (mg/dL) Preoperative Postoperative % increase of serum creatinine
Conventional clamp
220 (175–239) 24.4 (23–26) 50 (10–260)
235 (121–500) 50 (21–103) 100 (5–2500)
0.6 (0.5–0.81) 0.69 (0.52–0.86) 15 ( - 13 to 25)
0.78 (0.42–2.47) 0.85 (0.58–3.47) 9.51 ( - 20 to 132)
P value .3658 < .001 .5154 .1736 .2873 .6554
Data are median values (range).
minutes). The median blood loss was 50 mL (range, 10– 260 mL), and no blood transfusion was performed. No opening of the renal pelvis was noted in any patient. No postoperative complication occurred. The histopathological diagnosis was renal cell carcinoma clear cell, and the resected stump was negative in all patients. The median serum creatinine level was 0.6 (range, 0.5–0.81) mg/dL before surgery and 0.69 (range, 0.52–0.86) mg/dL 6 months after surgery. The median estimated glomerular filtration rate was 85.01 (range, 76–97.4) mL/minute/1.73 m2 before surgery and 79.76 (range, 68.4–90) mL/minute/1.73 m2 6 months after surgery. There were no Clavien–Dindo complications at the 90-day follow-up. At a mean follow-up of 17 months no recurrence was noted. Peri- and postoperative parameters of clamping were compared with those of conventional clamping in our institute (Table 1). No significant differences were observed in total operative time (220 minutes versus 235 minutes), median blood loss (50 mL versus 100 mL), and serum creatinine percentage change (serum creatinine level preoperatively versus 6 months after surgery, 15% versus 9.51%). Discussion
The concept of trifecta outcomes during robot/laparoscopic partial nephrectomy, with the three key outcomes of a negative cancer margin, minimal function decrease, and no urological complications, has been realized.5 To minimize reduction of the renal function, it may be necessary to minimize the warm ischemia time, for which cooling, a nonischemic method, or limited range of ischemia is considered. Sufficient cooling of the clamped renal artery and vein may be useful. This procedure is widely used in open surgery and may be applicable for laparoscopic surgery using a retroperitoneal approach,6 but effective cooling is technically difficult for surgery through a peritoneal approach. Thus, this procedure may be not useful. Partial ischemia procedures using various energy devices have been investigated, including an ultrasonically activated bending scalpel,7 water-jet dissector,8 diode laser,9 floating-ball radiofrequency dissector,10 microwaves,11 and radiofrequency coagulation.12 These are very useful for intraoperative hemostasis, and bleeding may be controlled with them. However, the margin cannot be readily decided because differentiation between normal renal tissue and the tumor is difficult. Thus, heat damage to the surrounding tissue, such as arteries, veins, and the calix, is of concern. Actually, unex-
pected collateral thermal damage to the surrounding structures, especially the collecting system, may cause urinoma, pelvicalyceal stenosis, and renal arteriovenous fistula.11,13,14 Because these complications have been reported, the indication may be limited to small protruding tumors. The main problem in partial nephrectomy under ischemia is that accurate resection and suture have to be performed within a limited time, placing mental pressure on operators. With an open jaw diameter of 70 mm, the Simon clamp is novel in that it has a standard ratchet handle that can be locked into place, thereby preventing clamp sliding, while curved jaws evenly distribute a constant and uniform pressure.4 As previously reported, partial ischemia using a kidney grasper requires no skilled laparoscopic technique, while ischemic damage of renal nephrons can be minimized, which may be the main advantage.15,16 For solitary kidney cases, damage to the renal function by surgery is a more serious concern, and it has been stated that partial ischemia is more appropriate than the method of applying complete ischemia to the hilum of the kidney.17 We think that the applicability of partial ischemia using this procedure should be judged in sufficient consideration of the tumor location and diameter. In addition, reconsideration of the positioning of an insertion port may also be necessary. However, application may be difficult depending on the tumor location, and tumors located in the superior or inferior pole (i.e., 25-mm or smaller protruding tumors located at the superior or inferior pole) may be favorable indications. This procedure may be a useful option in ischemia for partial nephrectomy. In our experiences, the procedure was switched to arterial ischemia in one of the 5 patients. Because the patient was the first case undergoing this procedure, we switched to arterial ischemia in the early phase, but this was considered sufficiently achievable in a later investigation. Parenchymal regional ischemia has been attempted using other methods, and the utility was reported. Previously reported methods of laparoscopic regional ischemia have ranged from a loop tourniquet or bands to commonly used vascular clamps. Parenchymal regional ischemia has been used to avoid complete vascular occlusion during partial nephrectomy.18–21 Zero ischemia using a clip for neurosurgery has been reported.22 There has been no report from other institutions, and this procedure may be used only at very limited facilities. This anatomical vascular microdissection of the artery first and then the tumor allows even complex tumors to be excised without hilar clamping. Compared with these, the Simon clamp may be easy to handle.
798 Conclusions
Selective renal parenchymal clamping during laparoscopic partial nephrectomy is feasible and an effective method to perform maximal nephron-sparing surgery without the need for warm ischemia for selective cases. Disclosure Statement
No competing financial interests exist. References
1. Motzer RJ, Agarwal N, Beard C, Bolger GB, Boston B, Carducci MA, Choueiri TK, Figlin RA, Fishman M, Hancock SL, Hudes GR, Jonasch E, Kessinger A, Kuzel TM, Lange PH, Levine EG, Margolin KA, Michaelson MD, Olencki T, Pili R, Redman BG, Robertson CN, Schwartz LH, Sheinfeld J, Wang J. NCCN clinical practice guidelines in oncology: Kidney cancer. J Natl Compr Canc Netw 2009;7:618–630. 2. Ljungberg B, Cowan NC, Hanbury DC, Hora M, Kuczyk MA, Merseburger AS, Patard JJ, Mulders PF, Sinescu IC; European Association of Urology Guideline Group. EAU guidelines on renal cell carcinoma: The 2010 update. Eur Urol 2010;58:398–406. 3. Fujioka T, Obara W; Committee for Establishment of the Clinical Practice Guidelines for the Management of Renal Cell Carcinoma; Japanese Urological Association. Evidence-based clinical practice guidelines for renal cell carcinoma (summary—JUA 2007 edition). Int J Urol 2009;16: 339–353. 4. Simon J, Bartsch G Jr, Finter F, Hautmann R, de Petriconi R. Laparoscopic partial nephrectomy with selective control of the renal parenchyma: Initial experience with a novel laparoscopic clamp. BJU Int 2009;103:805–808. 5. Hung AJ, Cai J, Simmons MN, Gill IS. ‘‘Trifecta’’ in partial nephrectomy. J Urol 2013;189:36–42. 6. Tatsugami K, Tanaka S, Ohtsubo S, Inokuchi J, Yokomizo A, Kuroiwa K, Song YH, Naito S. Causes of diminished renal function in the affected kidney after partial nephrectomy. BJU Int 2012;110:E357–E361. 7. Harmon WJ, Kavoussi LR, Bishoff JT. Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears. Urology 2000;56:754–759. 8. Moinzadeh A, Hasan W, Spaliviero M, Finelli A, Kilciler M, Magi-Galluzzi C, El Gabry E, Desai M, Kaouk J, Gill IS. Water jet assisted laparoscopic partial nephrectomy without hilar clamping in the calf model. J Urol 2005;174: 317–321. 9. Ogan K, Jacomides L, Saboorian H, Koeneman K, Li Y, Napper C, Hoopman J, Pearle MS, Cadeddu JA. Sutureless laparoscopic heminephrectomy using laser tissue soldering. J Endourol 2003;17:295–300. 10. Sundaram CP, Rehman J, Venkatesh R, Lee D, Rageb MM, Kibel A, Landman J. Hemostatic laparoscopic partial nephrectomy assisted by a water-cooled, high-density, monopolar device without renal vascular control. Urology 2003;61: 906–909.
HONGO ET AL.
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Address correspondence to: Fumiya Hongo, MD, PhD Department of Urology Kyoto Prefectural University of Medicine 465 Kajii-cho Kamigyo-ku 602-8566, Kyoto Japan E-mail: [email protected]
