Cleveland Clinic’s Glickman Urological and Kidney Institute has pioneered a practice model that lends itself to close cooperation between nephrology and urological surgery.
This pairing of the medical and surgical teams has improved our ability to treat renal cell carcinoma (RCC) while minimizing subsequent development of chronic kidney disease (CKD). To treat selected small renal masses and decrease the incidence of developing CKD, we have begun to employ non-ischemic nephron-sparing surgery (NSS) during robotic partial nephrectomy.
The ability to treat RCC with nephron-sparing surgery has seen a significant decrease in the development of chronic kidney disease (CKD) compared to the era when radical nephrectomy was routinely employed. As nephron-sparing surgery has become widely accepted, increasing emphasis has been placed on reducing surgical morbidity.
The 3D vision and wristed instruments of robotic technology have allowed many surgeons to master minimally-invasive partial nephrectomy for tumor removal and renal reconstruction compared to conventional laparoscopic partial nephrectomy.
Nevertheless, robotic partial nephrectomy requires a period of warm ischemia time (WIT.) Warm ischemia, compared to cold ischemia, is more likely to have a negative impact on subsequent renal function. WIT can result in the development of acute kidney injury (AKI), CKD, and even permanent dialysis.
Furthermore, many incidental renal masses are discovered in elderly patients and those with diabetes and hypertension. The incidence of CKD in these patients is 38%, 35%, and 29%, respectively. As CKD predisposes to AKI, any attempt to minimize or eliminate WIT during robotic partial nephrectomy could potentially decrease or avoid renal injury.
Contemporary studies now suggest the amount of renal parenchyma remaining after partial nephrectomy is the main determinant of subsequent renal function.
This, however, is a non-modifiable factor. Decreasing or eliminating WIT, however, is a modifiable factor that can improve functional nephrologic outcomes. Techniques that require isolating (Figure 1) and controlling segmental renal vessels are technically complicated, making widespread adoption difficult. Our procedure, though, is easily transferable as it uses techniques familiar to most surgeons performing robotic renal procedures.
The technique we have begun to use in selected patients with solitary or multiple small exophytic renal tumors uses pre-placement of renorrhapy sutures prior to tumor removal (Figure 2). These are partially tightened, affording a relatively bloodless field.
After tumor removal, while awaiting frozen section results from the pathologist, the surgeon secures the exposed renal parenchyma with several running sutures and then tightly secures the renorrhapy sutures. Rolled hemostatic fabric and other agents are often used to obtain optimal hemostasis. The pressure of the pneumoperitoneum is then reduced to assess for bleeding.
Although renorrhapy sutures are widely use for renal reconstruction after tumor removal during robotic partial nephrectomy, our novel approach of placing them prior to tumor excision (Figure 3) without cross-clamping the renal hilum avoids subjecting the kidney to any renal ischemia.
This lack of WIT minimizes the potential for renal damage. Furthermore this approach to NSS uses familiar techniques and is easily mastered by robotic surgeons currently performing renal surgery.