NARUS 2019: Kidney Hilum – Full Clamp
1. Performing main renal artery clamping, using robotic bulldogs, and keeping the warm ischemia time below 25 minutes.
2. The tumor should be excised with a safe margin, preferably using a robotic ultrasound during the procedure
3. A two-layer closure should be performed using sliding clip renorraphy, with a deep inner running layer (using 3-0 Monocryl), and outer interrupted capsular layer (using 2-0 Vicryl).
Before moving forward with the clamping, Dr. Rogers stresses the importance of performing a pre-clamp checklist in every case, which makes sure that all required tools are available and all team members understand what the next stage is. According to this checklist, the surgeon needs to make sure that all sutures are available and prepared correctly, that the trocars are not out of the fascia, and needle drivers are not expired, that the camera is clean and ready, that there is enough CO2 for insufflation, that adequate hydration is available, that all necessary surgical tools are at reach, including bulldogs, Satinsky clamp, GIA stapler, an open tray, and lastly, that no breaks are conducted during the clamp time.
The robotic bulldog clamps can be placed by the assistant, or by the surgeon, by using a prograsp and grasping the specified notch on the bulldog, enabling the surgeon to place the bulldog wherever he/she sees fit.
The ultimate goal of robotic partial nephrectomy, aside from removing the renal tumor, is to preserve renal function by decreasing ischemia time. Over the years many various techniques and improvisations have been developed in an attempt to decrease ischemia time. These include selective clamping, early unclamping, off-clamp resection, and intracorporeal hypothermia. However, a recent study has demonstrated that the standard total clamping still predominates, even among skilled surgeons and in very complex cases, with 75% of surgeons performing complete clamp.1
Before concluding his talk, Dr. Rogers demonstrated some important myths that have been proven to be incorrect over the years:
1. ”Every minute of warm ischemia causes irreversible damage” – data have shown that limited ischemia (<20-25 minutes) has minimal effects on long-term renal function2,3
2. ”Ischemia time is the number one factor in preserving renal function. It has been shown that for limited ischemia, the quantity and quality outweigh speed.4,5
3. ”Off-clamp or selective clamping is the standard of care” – there is a minimal benefit with off-clamp surgery unless compared to extremely long warm ischemia time or the patient has chronic kidney disease (6,7)
Dr. Rogers summarized his talk and stated that complete clamping is almost always appropriate for all cases, and there is no need to make it harder than it needs to be. It is important to keep clamping time as short as possible, perform excision with a good margin, and perform a two-layer renorraphy, utilizing the sliding clip technique.
Presented by: Craig Rogers, MD, Henry Ford Health System, Detroit, Michigan
Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at 2019 3rd Annual North American Robotic Urology Symposium (NARUS), February 8-9, 2018 - Las Vegas, Nevada, United States
References:
1. Lieberman L et al. J. Endourol 2017
2. Lane B et al. Comparison of Cold and Warm Ischemia During Partial Nephrectomy in 660 Solitary Kidneys Reveals Predominant Role of Nonmodifiable Factors in Determining Ultimate Renal Function. J Urol 2011 Feb;2:421-427
3. Parekh et al. Am. J. Phys 2013
4. Minervi et al. J Urol 2011
5. Lango et al. Eur J. Surg. Onc 2014
6. Porpiglia F. et al.Temporary implantable nitinol device (TIND): a novel, minimally invasive treatment for relief of lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia (BPH): feasibility, safety and functional results at 1 year of follow‐up. BJUI 2015 Aug;116(2):278-287
7. Mir et al. J. Urol 2013
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Kidney Hilum – Incomplete Ischemia