Selective renal parenchymal clamping in nephron-sparing surgery

Abstract

Introduction and objectives: Different methods in minimizing renalischemia during nephron-sparing surgery (NSS) have been described.Apart from hilar or segmental arterial clamping, regional ischemia withcompression or various parenchymal clamps have been reported. Thecurrent video illustrates the technique and outcome of selective renalparenchymal clamping (SRPC) in NSS using an adjustable kidneyclamp. Materials and methods: A 65-year-old man was incidentally noted tohave a left upper pole renal mass on computed tomography (CT) of thethorax while undergoing workup for an irregular lung nodule, whichwas negative on subsequent positron-emitted tomography (PET). Therenal mass was heterogeneously enhanced, partly exophytic andmeasured 28 9 26 9 23 mm, with SUV max 5.6 on PET andsuspicious of malignancy. The preoperative serum creatinine was76 lmol/L. Estimated glomerular filtration rate (eGFR) by Modificationof diet in renal disease study equation (MDRD) was >90 L/min/1.73 m2. Transperitoneal laparoscopic partial nephrectomy was performed usingthe standard 4-port technique. After mobilization of the descendingcolon, the Gerota’s fascia was incised and the upper pole tumor wasexposed with a circumferential rim of normal parenchyma of at least3 cm to prepare for parenchymal clamping. Hilar dissection was notperformed. The depth of the tumor was confirmed with intraoperativeultrasound. The adjustable kidney clamp (Karl Storz, Tuttlingen,Germany), consisting of a snare and ratchet, was then inserted througha 10-mm port and tightened across the upper pole with a 2 cm marginfrom the tumor edge to prevent slippage during excision and facilitatekidney positioning. Renorrhaphy was done with 2-O barbed sutures bysliding-clip technique. The parenchymal clamp was loosened graduallyto identify any bleeding. Hemostasis was aided with fibrin glue(Floseal), and then the edges of the Gerota’s fascia were apposed overthe renorrhaphy. Results: Total operating time was 168 mins and the parenchymalclamp time was 40 mins. The estimated blood loss was 200 mL. Thepatient had an uneventful recovery and was discharge on post-operativeday 7 with a serum creatinine of 75 lmol/L and eGFR of >90 L/min/1.73 m2. The pathology result showed a 3.5 cm clear cell type renalcell carcinoma of Fuhman’s grade 3 and cleared margins. From March2012 to March 2016, 30 patients had NSS with SRPC (18 robotic-assisted, 10 laparoscopic and 9 open). The mean PADUA score was7.19 ⊥1.00. Operative time was satisfactory at 211.3 ⊥64.9 mins and the mean blood loss was 207.6 ⊥186.7 mL. There was no significantmean post-operative change of serum creatinine at 7, 30 and 90 days.Conclusion SRPC is a safe and feasible alternative in minimizingrenal ischemia during NSS. Case selection depends on the feasibility ofapplying the clamp with an adequate margin for renorrhaphy, whilemaintaining the blood supply to the rest of the kidney.