Retroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping for cancer of the left upper calyx: a case report.

BACKGROUND: Currently, the standard treatment for renal pelvis carcinoma is radical nephroureterectomy with bladder cuff excision. To describe the feasibility of retroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping for cancer of renal pelvis, we report this special case for the first time. CASE PRESENTATION: A 67-year-old woman received this operation. Preoperative ureteroscopy revealed a papillary neoplasm with a pedicle in the upper calyx of the left kidney. After entering the retroperitoneal space and dissociating the renal artery and renal vein, the target artery was clamped beyond the final bifurcation before entering the parenchyma. After incision of the left renal parenchyma and exposure of the upper calyceal neck, the tumor was found confined to the upper calyx. Thereafter, the renal calyx and parenchyma were sutured successively after complete resection of the neoplasm. Postoperative pathological examination confirmed that the Grade I papillary carcinoma was confined to the mucosal layer. Thus far, there is no evidence of recurrence during the follow-up period for more than 42 months after surgery. CONCLUSIONS: Retroperitoneal laparoscopic partial nephrectomy with segmental renal artery clamping of the kidney provides a feasible treatment modality for noninvasive tumors that are limited to the calyx.

Renal Functional and Perioperative Outcomes of Retroperitoneal Robot-Assisted Versus Laparoscopic Partial Nephrectomy with Segmental Renal Artery Clamping.

Background: Retroperitoneal approach and segmental renal artery clamping in partial nephrectomy are techniques that facilitate postoperative recovery and renal function preservation. This study aimed to compare the renal function preservation and perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) with these techniques. Materials and Methods: Clinical parameters of 43 patients who had undergone retroperitoneal RAPN from March 2017 to December 2019 were retrospectively collected and compared with those of 52 patients who had undergone retroperitoneal LPN at the same period in our institution. Differences in operating time, warm ischemia time, estimated blood loss, complications, postoperative hospital stay, as well as renal function loss were compared between the two groups. Results: Background characteristics between RAPN and LPN groups such as age, gender, BMI, and tumor characteristics were comparable. All RAPNs and LPNs were successfully completed without conversion to open surgery or nephrectomy. No significant difference in operating time, estimated blood loss, complications, and postoperative hospital stay was observed between RAPN and LPN groups. The warm ischemia time in RAPN group was slightly shorter than that of LPN groups (P = .054). Compared with the LPN group, the RAPN group was significantly associated with less glomerular filtration rate reduction and renal volume loss rate (P = .042 and P = .013, respectively). Conclusions: The perioperative outcomes were comparable between the two groups. However, compared with LPN, RAPN had superiority in preserving renal function in our series.

Application of early sequential unclamping method in laparoscopic partial nephrectomy for patients with T1b renal tumor / 中华泌尿外科杂志

Objective To analyze the value of early sequential unclamping method in laparoscopic partial nephrectomy.Methods From April 2017 to October 2017,a total of 8 cases of renal tumor patients by early sequential unclamping method of laparoscopic partial nephrectomy (LPN) were reviewed,with 5 males and 3 females and average age of 56.4 years (43-70 years).Three cases of renal tumor were located on the left side,5 cases on the right side.The mean tumor diameter was 5.6 (4.6-6.4) cm.The preoperativeR.E.N.A.L.score was 8.8 (7-10),and the mean ASA score was 1.4 (1-2).Preoperative serum creatinine level was 89.5 (72.1-104.2) μmol/L,and the GFR level of the kidney with tumor before operation was 55.5 (40.4-62.3) ml/min.The early sequential unclamping method was used for retroperitoneal laparoscopic partial nephrectomy:according to the preoperative CTA results,the main branches and branches of the renal artery were routinely separated.Before the tumor resection,the branches of renal artery and the main renal artery were sequentially blocked.After removal of the tumor,the first layer of bare kidney wound blood vessels and collection system were sutured and repaired.Then released the main renal artery occlusion clamp,restored most of the blood supply to the kidney,but kept the tumor-specific segmental renal artery blocked.Continuous suture of the kidney created a rough combination of the renal wound.After second layers of suture completed,unclamped the segmental renal artery and sutured the renal wound again,made the third layers of suture intersecting with the second seam suture to strengthen the hemostatic effect.Results All the 8 patients were performed LPN with early sequential unclamping method successfully.The average operative time was 132.5 (90-180) min,the intraoperative blood loss was 142.5 (100-200) ml,the completely warm ischemia time was 15.5 (12.0-20.0) min,and no blood transfusion was performed intraoperatively and postoperatively.The operative margin was negative.The postoperative pathology showed that 7 cases were clear cell carcinoma and 1 cases of papillary cell carcinoma.Postoperative complications such as urinary leakage,incision infection and fever were not found.Drainage tube removal time was 3.5 (3-5) days and the time of postoperative hospitalization was 4.8 (4-6) days.At 1 months after operation,the serum creatinine level was 94.0 (83.6-101.2) μmol/L and the GFR level of one side kidney with tumor was 52.3 (43.2-59.6) ml/min.After 2-9 months of follow-up,there was no recurrence of the tumor.Conclusions Early sequential unclamping method could shorten the warm ischemia time and reduce the risk of bleeding during the operation.It also maintains a clear operative field,which could reduce the difficulty of laparoscopic partial nephrectomy and make a more accurate tumor resection in the complex renal tumor patients.

The study of selective segmental renal artery clamping aggravating pathological injury of the solitary-kidney in a porcine model / 中华泌尿外科杂志

Objective To evaluate the effect of selective segmental renal artery clamping ( SSRAC) on the solitary-kidney, providing a foundamental basis for the using of SSRAC in partial nephrectomy. Methods A total of 18 pigs were randomized equally into 2 groups according to the method of renal artery clamping such as main renal artery clamping ( MRAC) group or SSRAC group.Each case underwent right radical nephrectomy and either MRAC or SSRAC for 60 minutes on the left kidney.Serum creatinine ( SCr) and blood urea nitrogen (BUN) were measured before surgery and at 6 time points thereafter (the 1st, 7th, 14th, 21st, 28th, 90th day).Magnetic resonance imaging was performed before surgery and at 4 time points thereafter (the 1st, 7th, 28th, 90th day) and T2 relaxation time and apparent diffusion coefficient (ADC) were determined.Inflammatory cell infiltration and interstitial fibrosis were detected using renal histology on the 1st and 90th day after operation.Results SCr and BUN of the two groups increased to peak value on the 1st day, and then decreased gradually to normal on the 90th day after the operation.On the 1st day, SCr [(266.43 ±31.12)umol/l] and BUN [(13.63 ±2.54)mmol/l)] of SSRAC group were significantly lower than that of MRAC [(386.37 ±40.40)umol/l,(26.83 ±5.96)mmol/l] (P0.05) on the 7th, 14th, 21st, 28th, 90th day.In the MRAC group, the T2 relaxation time of upper, middle and lower pole of the left kidney increased and the ADC decreased on the 1st day after operation.It arrived to the peak value on the 7th day, and decreased or increased respectively from then on to normal level on the 90th day.In the SSRAC group, there were no significant changes of T2 relaxation time and ADC in the upper and middle pole of left kidney (P>0.05), but it was similar to that in the MRAC group for lower pole.On the 1st, 7th, 28th day after operation, the T2 relaxation time of upper and middle pole of the left kidney in the MRAC group [(45.50 ±1.87),(51.82 ±2.27), and(40.37 ±1.93)ms ) ] were significantly higher than those in the SSRAC group [(36.67 ± 1.33),(35.15 ±1.27), and(37.48 ±1.37)ms](P0.05).On the 1st, 7th, 28th day after operation, the ADC of upper and middle pole of the left kidney in the MRAC group [(2.29 ±0.08) ×10 -3 mm2/s, (2.10 ±0.08) ×10 -3 mm2/s, (2.41 ±0.09) ×10 -3 mm2/s] were significantly lower than that of the SSRAC group [(2.69 ± 0.08) ×10 -3 mm2/s, ( 2.63 ±0.06 ) ×10 -3 mm2/s, ( 2.68 ±0.05 ) ×10 -3 mm2/s ] ( P <0.05 ) . However, on the 1st,7th, 28th, 90th day after operation, the ADC of lower pole of the left kidney in the SSRAC group [(1.93 ±0.08) ×10 -3mm2/s,(1.91 ±0.09) ×10-3mm2/s,(2.33 ±0.07) ×10 -3mm2/s, and (2.43 ±0.07) ×10 -3 mm2/s] were significantly lower than those of the MRAC group [ (2.37 ±0.05) ×10 -3 mm2/s, (2.06 ±0.07) ×10 -3 mm2/s, (2.46 ±0.09) ×10 -3 mm2/s, (2.61 ±0.08) ×10 -3 mm2/s](P<0.05).The whole left kidney in MRAC group experienced extensive tubular hydropic degeneration and limited inflammatory cell infiltration on the 1st day after operation.Moreover, renal tubular hydropic degeneration alleviated and no glomerular changes, fibrous tissue hyperplasia or inflammatory cell infiltration was found on the 90th day after operation.In SSRAC group, no changes were found in upper and middle pole of left kidney at the two time points, while the pathological injury of the lower pole of left kidney was more severe.Conclusions SSRAC has obvious protective effect on renal function in the early stage. However, compared with MRAC, the renal tissue injury in the ischemic area was more serious.Therefore, to protect renal function in partial nephrectomy, the ischemic renal area should be reduced as much as possible, even to zero-ischemic, when adopting SSRAC.