BERKELEY, CA (UroToday.com) - Taken together these two articles provide two important pieces of information for the surgeon involved with laparoscopic partial nephrectomy. Firstly, ischemic preconditioning in the porcine kidney (for 25 or 60 minutes) had no beneficial impact on subsequent response of the kidney to 90 minutes of warm ischemia. Specifically, either 4 cycles of 4 minutes of warm ischemia followed by 11 minutes of reperfusion (60 minute model) or 10 minutes of warm ischemia followed by 15 minutes of reperfusion (25 minute model) was used. Secondly, clamping the renal artery or both the artery and vein during laparoscopic warm ischemia had equal impact on the kidney during warm ischemia whereas, clamping the artery only was beneficial during open surgery. The pneumoperitoneum effectively decreases renal blood flow thereby largely mimicking what is achieved by clamping both renal artery and vein. These two findings have direct clinical impact. Firstly, ischemic preconditioning will likely be of little value during laparoscopic partial nephrectomy and second, it may be prudent to dispense with the dissection and individual clamping of the renal artery with a bulldog or bulldogs and instead just broadly dissect the hilum and clamp the entire hilum with a Satinsky clamp. The use of the Satinsky clamp does necessitate placement of an additional 10 mm port; however, hilar dissection is less extensive and seemingly more rapid, risk of damage to the renal vessels may be further limited, and the security of the clamping and reliability of the unclamping procedure are facilitated. At our institution, I have switched from use of the bulldogs to employment of a double locking Satinsky clamp as practiced by Gill and associates at the Cleveland Clinic.

Orvieto MA, Zorn KC, Meniola FP, Gong EM, Lucioni A, Mikhail AA, Gofrit ON, Shalhav AL

Urology. 69(5):984-987, May 2007
doi:10.1016/j.urology.2007.01.100

Orvieto MA, Zorn KC, Mendiola F, Lyon MB, Mikhail AA, Gofrit ON, Shalhav AL

J. Urol. 177(6): 2371-2374, June 2007
doi:10.1016/j.juro.2007.01.115

UroToday.com Laproscopic and Robotic Section

Written by Ralph V. Clayman, MD, a Contributing Editor with UroToday.

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