Surgery in MotionApplication of a Vasculature Model and Standardization of the Renal Hilar Approach in Laparoscopic Partial Nephrectomy for Precise Segmental Artery Clamping
Introduction
Nephron-sparing surgery leads to less chronic kidney disease and fewer cardiovascular events compared with radical nephrectomy for patients with small renal tumors [1], [2], [3]. Minimizing warm ischemia injury is one technical focus to improve the functional outcomes of nephron-sparing surgery. For this purpose, one method is to decrease warm ischemia time (WIT). Recent literature confirmed that WIT remains an important modifiable feature associated with short- and long-term renal function [4], [5]. On the other hand, it is to reduce the warm ischemia area.
The main technique involved is selective artery clamping [6], [7], which potentially improves short-term postoperative renal function compared with main renal artery clamping [6]. Clamping of highly selective feeding arteries requires hilar microdissection [7], which is technically challenging without an understanding of the renal vasculature characteristics. The emergence of a high-quality three-dimensional vasculature model meets the requirements of precise clamping technique, which can orient the surgical procedure. Routinely dissecting target arteries from the posterior hilum was not effective enough, as some procedures needed converse to main renal artery clamping in our previous study [6].
Based on accumulated experience, we have set up a standard practice of an optimal hilar approach based on the vascular model to dissect target-feeding arteries. We present stepwise details on the application of the renal vasculature model and the standardized renal hilar approach in segmental renal artery dissection for the laparoscopic partial nephrectomy (LPN).
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Methods and patients
We retrospectively analyzed a consecutive series of 82 patients who underwent LPN with precise segmental renal artery clamping from December 2009 to June 2011. The study was approved by the institutional review board of the Nanjing Medical University. Inclusion criteria for LPN were a single, organ-confined mass of 4 cm with a normal contralateral kidney. Patients with a 4- to 7-cm tumor were also included if resection was deemed technically feasible. All patients received dual-source computed
Results
Tumor characteristics, clamping numbers, and hilar approaches were analyzed before the operations based on the vasculature model (Table 1). The median tumor size was 3.0 cm, and 22% of the tumors were >4 cm. Polar, anterior, posterior, and striding tumors made up 24.4%, 28.0%, 18.3%, and 29.3% of the tumors, respectively. Clamping numbers were determined in the model. A single target artery was the most common, in 51.2% of all patients; three target arteries were the least common, in only 9.8% of
Discussion
Warm ischemia injury remains an important factor influencing postoperative renal function in nephron-sparing surgery [4], [5], [10]. Many novel techniques have emerged to minimize warm ischemia injury. One promising method is to convert global parenchymal ischemia to regional ischemia. Renal vascular segmentation provides the theoretical possibility of regional ischemia during nephron-sparing surgery. However, the variability of the renal vasculature and the complexity of the intrahilum
Conclusions
The renal vasculature model based on high-quality three-dimensional DSCT angiography provides important orientation for LPN with precise segmental artery clamping. Standardization of appropriate hilar approaches according to the model optimizes the surgical procedures and leads to satisfactory surgical outcomes.
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These authors contributed equally.