V5-04: Robotic-assisted Laparoscopic Partial Nephrectomy with Intracorporeal Cooling for a Renal Mass
VideoIntroductions and Objectives
The application of robotics to renal surgery has allowed for re-creation of open surgical principles in a minimally invasive fashion. From open surgery it is known that in-situ renal hypothermia prevents renal ischemic injury during prolonged hilar clamping. A renal temperature of 18-20°C is required for optimal preservation. The aim of this video is to describe our technique for intracorporeal cooling with ice slush during robotic partial nephrectomy, with real time parenchymal temperature monitoring.
A 74 year-old male presented with an enhancing 3 cm endophytic hilar right renal mass. The R.E.N.A.L. nephrometry score was 8a. Pre-operative serum Creatinine was 1.32 mg/dL. Decision was made to proceed with a robotic right partial nephrectomy with intracorporeal cooling, given the high complexity of the tumor. The kidney was mobilized and the hilum was dissected. The kidney was then surrounded with an18x4 inch sponge. Ice slush was introduced through an additional 12 mm laparoscopic port placed posterior to the mid axillary line. Ice was placed posterior to the kidney then the hilum was clamped. Additional ice was placed over the medial aspect. After cooling, which was monitored by a thermocouple introduced into the normal kidney parenchyma, tumor excision was initiated, keeping ice covering most of the normal kidney at all times.
Operative time was 183 minutes. Total ischemia time was 27 minutes and estimated blood loss was 50 cc. The lowest parenchymal temperature was 14.1°C. The patient’s temperature only dropped by 0.6°C during cooling. There were no intraoperative or perioperative complications. Serum Creatinine one week postoperatively was 1.43 mg/dL. The final pathology was a 2.5cm clear cell renal cell carcinoma, Fuhrman grade 4. The resection margins were negative.
Robotic partial nephrectomy with intracorporeal ice slush cooling is technically feasible. We present our simplified technique with real-time renal parenchymal temperature monitoring. We have performed this technique in 4 patients and were able to achieve renal temperatures of 2 days was observed. However, further improvements in the ice delivery system are required for universal adaptation of this method. Finally long-term renal functional outcome data is needed to fully validate this technique.