V4-07: Unclamped Robotic Assisted Laparoscopic Partial Nephrectomy: Demonstration of the Sequential Preplaced Suture Technique

Video

Introductions and Objectives
Partial nephrectomy is the gold standard for the surgical management of the small renal mass. The application of robotic surgery has allowed achievement of the surgical outcomes comparable to the open approach including warm ischemia times (WIT), oncologic outcomes, and complication rates. It has recently been shown that renal functional outcomes after partial nephrectomy is influenced by both WIT and the amount of normal parenchyma resected. However, the goal remains to minimize WIT whenever possible. Recently unclamped partial nephrectomy has gained popularity in an effort to eliminate ischemic insult to the kidney altogether. A number of different techniques have been described, however resection off clamp often incurs a higher blood loss. We present our unclamped sequential pre-placed suture technique for resection of an exophytic enhancing renal mass that eliminates global ischemia and minimizes parenchymal bleeding.

Methods
Our illustrative case is of a 71 year old male with chronic renal insufficiency was found to have a left lower pole 3.5 cm exophytic enhancing renal mass on cross sectional imaging. The R.E.N.A.L. nephrometry score was 4a. His serum Creatinine was 2.59 mg/dL at baseline. Decision was made to proceed with a left robotic partial nephrectomy using our unclamped sequential pre-placed suture technique. After mobilizing the kidney, initial suture is placed in proximity to the planed excision line just enough to cut between the suture and the tumor capsule. Tumor exicion is continued till bleeding is just starting followed by a second hemostatic suture in the already excised area. This is repeated till the mass is completely excised and the excision bed sutured sequentially. Surgical technique and technical considerations are outlined in the accompanying video.

Results
Eleven patients who underwent robotic partial nephrectomy between 2008 and 2013 were treated with the sequential pre-placed suture technique by a single surgeon. Two patients had resection of multiple tumors, with at least one tumor resected off clamp. Median tumor size was 2 cm, mean EBL was 135 cc, and mean operative time was 170 minutes. The 2 patients with multiple tumors had a mean WIT of 14.75 min. All resection margins were negative.

Conclusions
Sequential pre-placed suture renorrhaphy technique is a safe and effective technique that is useful in renal function preservation by limiting or eliminating WIT, while aiding in maximizing nephron preservation, especially in those patients with solitary kidneys and multiple tumors.

Funding: none