V5-10: Selective Renal Artery Clamping: Right Robotic Assisted Hemi-Nephrectomy and En Bloc Andrenalectomy in A Duplicated System

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Introductions and Objectives
Several techniques have been employed to reduce warm ischemic time (WIT) in partial nephrectomy: vasodilators, antioxidants, agents to reduce cellular swelling, and recently, selective renal arterial clamping. We have adopted the latter technique in select cases. We present a 71 year old male who was found to have a 5.5 centimeter(cm) renal mass, involving a posterior, cephalad right renal moiety of a duplicated system (Nephrometry score=8a). The mass abutted the medullary sinus without gross involvement of the right adrenal gland. The left adrenal appeared normal. Our aim was to use selective clamping of the involved renal artery branches to allow definitive resection of the upper pole tumor and adrenal while preserving blood flow to the lower moiety.

Methods
To facilitate an upper pole heminephrectomy, en bloc adrenalectomy was elected. A standard trans-peritoneal robotic approach was used to approach the right renal mass. The right adrenal vein was secured with a clip and Ligasure used to divide the right adrenal vein and infrahepatic attachments to isolate the upper pole and adrenal off the psoas. A bulldog clamp was applied to the upper pole renal artery branch. The upper moiety mass was resected from medial to lateral in standard fashion freeing it from the medullary sinus an. Renorraphy was compeleted with 0-Vicryl over Floseal and Surgicel.

Results
The upper pole moiety tumor was resected en bloc with the attached right adrenal gland. WIT was 21 minutes and EBL was 300cc. Pathology revealed a 5.5cm conventional renal cell carcinoma (RCC) with negative margins and an uninvolved adrenal gland.

Conclusions
Selective renal artery clamping for right robotic assisted hemi-nephrectomy and en bloc andrenalectomy in a duplicated system was performed safely and effectively. This case adds to evidence supporting the safety and effectiveness of selective renal artery clamping in select cases._x000D_ _x000D_ Question:_x000D_ In a 2009 study, which of the following variables was predictive of adrenal involvement by RCC at the time of ipsilateral partial nephrectomy. _x000D_ 1) Age_x000D_ 2) Gender_x000D_ 3) Renal tumor size*_x000D_ 4) Renal tumor side (left versus right)_x000D_ 5) Renal tumor location_x000D_ _x000D_ In a 2009 study by Lane et al, multivariate analysis revealed that adrenalectomy at the time of partial nephrectomy was advocated in only 2 situations: radiographically suspicious adrenal lesions and improving feasibility of removing upper pole tumors as with our case.

Funding: None