V9-06: Robotic partial nephrectomy for hilar tumors: zero ischemia or early unclamping?

Video

Introductions and Objectives
An arterial clamping is usually performed during partial nephrectomy in order to decrease blood loss and improve vision during tumorectomy. However, it causes warm ischemia which is potentially harmful for the kidney. The concept of “zero ischemia” robotic partially nephrectomy appeared in the early 2010’s. Its aim is to avoid warm ischemia time by omitting to clamp the main renal artery. The aim of this video was to compare two managements of the renal pedicle during robotic partial nephrectomy for hilar tumors: early unclamping vs. zero ischemia.

Methods
We present 2 cases of robotic partial nephrectomy for complex (RENAL NEPHROMETRY score ≥ 7) and hilar tumors._x000D_ In the first case, a 6 cm tumor of the left kidney has been diagnosed in a 57 year-old male. RENAL NEPHROMETRY score was 10-ph. The main renal artery was clamped with an early unclamping (unclamping after one or two running suture in the tumor bed but before parenchymal repair). _x000D_ In the second case, a 4 cm totally endophytic tumor of the left kidney arised in a 66 year-old male. RENAL NEPHROMETRY score was 9-h. An off-clamp technique was chosen.

Results
_x000D_ In the first case, warm ischemia time was 24 minutes and estimated blood loss was 500 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 5. Surgical margins were negative. At 1 month postoperatively, 88% of renal function was preserved._x000D_ In the second case, an important bleeding occurred during tumorectomy. First, the surgeon switched to a selective arterial clamping. The bleeding continued and the surgeon had to clamp the main renal artery. Warm ischemia time was 8 minutes and estimated blood loss was 1200 mL. There were no transfusions or postoperative complications. The patient was discharged on postoperative day 4. Surgical margins were negative. At 1 mont postoperatively, 86% of renal function was preserved.

Conclusions
Hilar tumors are good candidates for the “zero ischemia” techniques during robotic partial nephrectomy. However, they could lead to important bleeding that could increase the surgical morbidity and the risk of positive margins. As recent data suggest that a limited warm ischemia time (

Funding: none