Introduction: Partial nephrectomy (PN) in autosomal dominant polycystic kidney disease (PCKD) is desirable in the setting of chronic kidney disease, but presents a technical challenge because of the presence of innumerable cysts and abnormal renal architecture. Prior reports of PN in PCKD have described prolonged warm ischemia time and decreased postoperative renal function.1 Off-clamp, or zero-ischemia, PN may mitigate renal function losses after oncologic surgery.2 Here, we present a video describing our technique for off-clamp robot-assisted PN in PCKD.
Methods: In this Institutional Review Board-approved study, we used the Northwestern University Enterprise Data Warehouse to perform a retrospective review of patients with PCKD who underwent off-clamp robot-assisted PN.
Results: Two patients with PCKD underwent off-clamp robot-assisted PN. In the presented case, a 66-year-old man presented with a 4-cm right renal mass. MRI and contrast-enhanced ultrasonography were used preoperatively to delineate the mass, and interventional radiology biopsy was consistent with malignancy. The kidney was mobilized and the hilum was isolated laparoscopically in the usual manner. At our training institution, laparoscopic mobilization is utilized to improve and maintain laparoscopic skills. A large cyst was decorticated to provide adequate access to the mass. The da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) was docked for tumor excision. The renal mass was excised sharply, using judicious bipolar electrocautery with the Maryland bipolar forceps or LigaSure device (Medtronic, Minneapolis, MN) to control feeding vessels. Typical sliding-clip renorrhaphy was omitted because of the lack of normal renal parenchyma, and instead the remaining feeding vessels were oversewn with absorbable suture before the application of hemostatic agents over the resection bed (FloSeal; Baxter Healthcare, Deerfield, IL and Surgical; Ethicon, Somerville, NJ). Final pathology analysis revealed pT1b renal cell carcinoma, mixed papillary types 1 and 2, high grade. Estimated blood loss was 200 mL, postoperative hemoglobin was 10.9 g/dL from 11.7 g/dL, and the patient's most recent estimated glomerular filtration rate (GFR) was unchanged from preoperative baseline (49 mL/min). In the second case, pathology analysis revealed pT1b papillary renal cell carcinoma, estimated blood loss was 500 mL, and postoperative laboratories were also stable from baseline (hemoglobin 10.6 g/dL from 10.7 g/dL; estimated GFR was 41 mL/min from 37 mL/min).
Conclusions: Off-clamp robot-assisted PN may be feasible in some cases wherein the tumor is not in close contact with thick renal parenchyma. Limitations of this study include small sample size; however, zero-ischemia PN should be considered in patients with PCKD and chronic kidney disease.
No competing financial interests exists.
Runtime of video: 7 mins 53 secs
Presented at the North American Robotic Urology Symposium (NARUS), in Las Vegas, Nevada, on February 16, 2018.