V1080: Renovascular and tumor 3-D reconstruction to facilitate robot-assisted anatomical partial nephrectomy

Video

Introduction and Objectives
Unclamped (zero-ischemia) or selective-clamping have been proposed for partial nephrectomy (PN). Devascularizing the tumor and peri-tumor area is the key of these techniques. The objective of this study was to assess feasibility and efficacy of the surgical navigation by a reconstructed three-dimensional (3D) image of the renal vasculature and tumor to facilitate anatomical dissection of the tumor-specific Renal artery branches.

Methods
Ten patients underwent robot-assisted (n =9) or laparoscopic (n =1) anatomical “zero-ischemia” PN with the reconstructed 3D image-navigation. Median (range) tumor diameter and RENAL score were 4.8 cm (1.9-8 cm) and 10 (6-10), respectively. Pre-operatively, 3D image to fuse 3 key surgical anatomies, including 3D surface rendered renal tumor, transparent kidney, and 3D course of the extra- and intra-renal arteries were reconstructed, using arterial phase and tumor-enhanced phase of the 0.5 mm step computed tomography (CT) volume data.

Results
Navigation: Reconstructed 3D image-navigation significantly facilitated performance of “zero-ischemia” PN without hilar clamping. Specifically, precise vascular dissection to identify the targeted Renal artery branches, and intra-operative safe decision of the radial nephrotomy incision were aided. This resulted in minimizing unnecessary ischemia or sacrificing of the healthy renal parenchyma. Intra-operative color Doppler ultrasonography and/or green dye contrast comparing between pre- and post- selective clamping confirmed specific de-vascularization of the tumor and immediate peri-tumor area, while maintaining uninterrupted arterial perfusion of the healthy renal parenchyma. Perioperative: Secondary and tertiary Renal artery branches dissection were performed in all cases without any vascular injury. There was no conversion to open surgery or to radical nephrectomy. The warm ischemia time was zero. The median (range) estimated blood loss, operative time and hospital stay were 175 ml (50-500 ml), 195 min (120-330 min) and 3 days (1-12 days), respectively. Pathology confirmed Renal Cell Carcinoma in 9 patients and all margins were found to be negative for cancer.

Conclusions
We developed a novel surgical navigation technique to employ 3D renal angiogram fused with 3D images of surface-rendered renal tumor and transparent kidney, to facilitate selective and superselective Renal artery branches dissection during anatomical (unclamped or selective clamping) partial nephrectomy.

Funding: None