Selective renal parenchymal clamping in robotic partial nephrectomy: initial experience

Objectives: To describe our early experience using a laparoscopic clamp to induce selective regional ischemia during robotic-assisted partial nephrectomy without hilar occlusion. The creation of a bloodless field during minimally invasive approaches to nephron-sparing surgery often requires complete warm ischemia with renal hilar clamping that can potentially result in subsequent renal damage.

Methods: After transperitoneal renal mobilization and delineation of the renal tumor margin using laparoscopic ultrasound, the laparoscopic clamp is placed across the renal parenchyma 2-3 cm proximal to the resection line. After tumor excision, the renal defect is repaired robotically and hemostatic agents are used to aid in achieving compressive hemostasis.

Results: Three patients with predominantly exophytic renal masses underwent this procedure for elective indications. Mean tumor diameter was 4.9 cm (range 1.2-7.0). Mean selective clamp time was 37 minutes (range 20-52). Estimated blood loss was minimal and no patients required renal hilar clamping. There were no perioperative complications. Mean change in preoperative and postoperative creatinine was 0.1 (±0.09). Final pathology revealed clear cell and papillary renal carcinomas with no positive margins on frozen or final evaluation.

Conclusions: Regional renal parenchymal clamping during robotic partial nephrectomy can be safely and effectively used to create a bloodless operative field in select patients with optimally located renal tumors. Our early experience with this technique allows for frozen pathologic evaluation of the tumor and margin status without concern for warm ischemia and represents another tool for surgeons performing minimally invasive nephron-sparing surgery.