V5-01: Robotic Partial Nephrectomy for Increasingly Complex Renal Masses in Solitary Kidneys Using Off Clamp and Early Unclamping Techniques
The indications for partial nephrectomy are expanding. The AUA guidelines state that partial nephrectomy is a standard option for healthy patients with clinical T1a and T1b renal masses. While most surgeons can choose the procedure that they are most comfortable with, there are a few imperative indications for partial nephrectomy including solitary kidneys. In this video, we demonstrate our technique of robotic partial nephrecgtomy for patients with solitary kidneys with emphasis of our off clamp and early unclamping techniques to minimize warm ischemia.
Since 2008 we have performed over 450 robotic partial nephrectomies, 12 of which were in solitary kidneys. Our port placement for the da Vinci Si and Xi are in figures 1 and 2. Typically small exopyhtic partial nephrectomies are done off clamp. For more endophytic or hilar tumors, clamping is performed with removal of the clamps as soon as there is hemostasis. For patients with multiple tumors, bulldog clamps are placed with the larger endophytic tumors are done first, then clamps are removed and the smaller and exophytic tumors are removed. Renorrhapy is performed in multiple layers using monocryl for the collecting system and small vessels, and interrupted vicryl for the medulla and cortex.
The median age of our series was 58 (48-73). The median warm ischemia time was 14 minutes with one ileus and one postoperative urine leak. There were no conversions to open. Postoperatively, 92% of the tumors were malignant with a mean decrease in eGFR of 30% (-68% - 0%) at a median follow up of 32 months.
Partial nephrectomy in patient with solitary kidney is a safe and feasible even for complex and multiple masses. The continued spread of technology and techniques may allow more patients to undergo nephron sparing techniques decreasing the risk of CKD and long term morbidity and mortality.