Precise Segmental Renal Artery Clamping Under the Guidance of Dual-source Computed Tomography Angiography During Laparoscopic Partial Nephrectomy

doi:10.1016/j.eururo.2012.05.056

European Urology

Volume 62, Issue 6, December 2012, Pages 1001-1008

https://doi.org/10.1016/j.eururo.2012.05.056 Get rights and content

Abstract

Background

Minimizing warm ischemic (WI) injury is one technical focus of partial nephrectomy (PN). Inducing regional ischemia in the tumor area by clamping segmental renal arteries has become an alternative method to decrease WI injury.

Objective

To study the technical feasibility of precise segmental artery clamping under the guidance of dual-source computed tomography (DSCT) angiography during laparoscopic partial nephrectomy (LPN) and to analyze the factors affecting surgical outcomes.

Design, setting, and participants

Retrospective analysis of 125 patients with unilateral kidney tumor treated from December 2009 to November 2011 with a mean follow-up of 18 mo.

Intervention

All patients received retroperitoneal LPN with the feeding segmental arteries precisely clamped. Most of the target branches were dissected close to the hilar parenchyma. The tumor was excised after precise clamping and renorrhaphy was performed.

Outcome measurements and statistical analysis

Univariable and multivariable logistic regression analyses were performed for categorical variables, and continuous variables were analyzed by linear regression.

Results and limitations

The target branches were isolated and clamped successfully in all patients without clamping the main renal artery. Median estimated blood loss (EBL) was 200 ml, and nine patients received blood transfusion. The accuracy of feeding artery orientation by DSCT angiography reached 93.6%. Tumor size, location, and growth pattern independently influenced the number of clamped branches. The number of clamped branches was significantly associated with postoperative renal function and EBL. Limitations of this study include its retrospective nature and that data are from a single-surgeon series.

Conclusions

The precise segmental artery clamping technique under the guidance of DSCT angiography is feasible and efficient to excise the tumor and to protect the normal parenchyma. The number of clamped branches is associated with tumor characteristics and can predict EBL and loss of renal function.

Introduction

Laparoscopic partial nephrectomy (LPN) is gaining popularity as a minimally invasive nephron-sparing treatment for selective renal tumors [1], [2], [3]. It is now well recognized that patients experience less severe chronic kidney disease and fewer cardiovascular events in the long term after nephron-sparing surgery compared to radical nephrectomy [4], [5]. Warm ischemic (WI) injury during PN is one of the important issues influencing short- and long-term renal function, and some novel techniques have emerged to decrease this injury, such as segmental renal artery clamping [6], zero ischemia [7], zero ischemia with vascular microdissection technique [8], [9], and a nonclamping technique [10]. Segmental renal artery clamping is a promising method and provides improved functional outcomes by decreasing WI injury [6]. However, in our previous study, segmental renal artery clamping was not very precise, and missed or inappropriate clamping might occur during the procedure [6]. Thus, a more refined surgical technique and higher quality of radiologic imaging are needed to obtain more satisfactory clinical outcomes. We present our experience using the precise segmental clamping technique under the guidance of dual-source computed tomography (DSCT) angiography in the past 2 yr.

Section snippets

Patients and methods

From December 2009 to November 2011, a total of 125 patients with renal tumors underwent LPN using the precise clamping technique. All operations were performed by the same laparoscopic surgeon (C.Y.). All patients had unilateral kidney tumor with diameters ranging from 1.4 to 7.0 cm; the contralateral kidney was normal. A glomerular ﬁltration rate (GFR) study was done to evaluate the split renal function by renal scintigraphy before and 3 min after the operation. Inclusion criteria for LPN with

Results

Patients’ general information and preoperative tumor characteristics are listed in Table 1. The median tumor diameter was 3.4 cm (range: 1.4–7.0 cm). The intrahilar feeding branch occupied 83.2% of all three anatomic variants. Surgical outcomes are listed in Table 2. The mean operating time was 87 min, and the median segmental clamping time was 24 min (range: 12–40 min). The median intraoperative blood loss was 200 ml (range: 50–800 ml). Target branches orientated by DSCT angiography could be isolated

Discussion

Renal artery clamping during PN can provide good intraoperative visualization and bleeding control, but inevitably causes WI injury. The WI time should be ≤20 min, as recent studies recommend [14], [15], [16]. Every effort, therefore, should be made to minimize WI intervals and priority should be given to methods that improve renal surgery paradigms to minimize ischemic parenchymal damage [17]. We previously reported our segmental renal artery clamping technique to obtain regional ischemia and

Conclusions

Our precise segmental clamping technique under the guidance of DSCT angiography is feasible and effective for excising renal tumors and protecting the normal parenchyma. This precise clamping technique further minimizes WI injury during LPN. Tumor size, tumor location, and growth pattern are associated with the number of clamped arterial branches. The number of clamped branches can predict short-term postoperative renal function.

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^†: These authors contributed equally.

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Platinum Priority – Kidney CancerEditorial by Inderbir S. Gill on pp. 1009–1010 of this issuePrecise Segmental Renal Artery Clamping Under the Guidance of Dual-source Computed Tomography Angiography During Laparoscopic Partial Nephrectomy

Abstract

Background

Objective

Design, setting, and participants

Intervention

Outcome measurements and statistical analysis

Results and limitations

Conclusions

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

J Urol

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

Eur Urol

J Urol

Eur Urol

Eur Urol

Eur Urol

Eur Urol

Platinum Priority – Kidney Cancer
Editorial by Inderbir S. Gill on pp. 1009–1010 of this issue
Precise Segmental Renal Artery Clamping Under the Guidance of Dual-source Computed Tomography Angiography During Laparoscopic Partial Nephrectomy