Surgery in MotionRobotic Unclamped “Minimal-margin” Partial Nephrectomy: Ongoing Refinement of the Anatomic Zero-ischemia Concept
Introduction
The role of partial nephrectomy (PN) in the management of small renal masses (SRMs) remains controversial; however, the significant prevalence of chronic kidney disease (CKD) and its associated morbidity argue in favor of nephron-sparing approaches [1], [2], [3], [4]. The adoption of laparoscopic and robotic PN has been propelled by equivalent oncologic and functional outcomes compared with the open approach [5].
Recent technical refinements have been aimed at optimizing surgically modifiable factors, such as warm ischemia, starting initially with early unclamping and subsequently with selective segmental artery clamping [6], [7], [8], [9]. We described an anatomic PN technique aimed at tumor-specific devascularization, with the goal of eliminating global ischemia to the renal remnant [6]. The goals of further minimizing functional parenchymal loss and altogether eliminating global renal ischemia remain. The primary aim of this paper is to describe the technical feasibility and early outcomes of completely unclamped, “minimal-margin,” robotic PN. To place this in the context of overall stepwise evolution of our anatomic PN approach, we also evaluated the impact of this technical progression on perioperative outcomes.
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Study population
From October 2009 to February 2013, 320 patients with renal tumors underwent minimally invasive PN by a single surgeon, and 208 (65%) of those patients underwent anatomic PN surgery. Patient selection for anatomic PN was at the discretion of the operating surgeon. A total of 179 patients consented to have their data prospectively collected in our institutional review board–approved database and compose the study cohort. Preoperative workup included clinical and laboratory evaluation and
Results
Anatomic PN was performed in 179 patients who were retrospectively divided into three groups based on operative technique. The groups were comparable in terms of age, sex, body mass index, and comorbidities (Table 1). Baseline renal function was also similar among the groups, including incidence of CKD stage ≥3 (23–26%, p = 0.95). Nearly 10% of patients in each group had a solitary kidney. Median tumor size on CT was similar across groups (3.0 cm [range: 0.9–13.6], 3.4 cm [range: 1.3–7.9], 3.4 cm
Discussion
In this study, we examined the careful technical evolution of anatomic robotic PN from superselective clamping after vascular microdissection toward a completely unclamped approach. These data are in keeping with our earlier observation of functional benefits stemming from reducing or eliminating global renal ischemia. Specifically, volume-adjusted renal functional outcomes improved significantly as we progressed from conventional hilar clamping to early unclamping to superselective techniques
Conclusions
Our findings support the safety and feasibility of anatomic PN throughout its technical evolution. In addition, the unclamped minimal-margin technique may reduce intraoperative blood loss and yield superior early functional outcomes.
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These authors contributed equally.