Halving Ischemia Time During Laparoscopic Partial Nephrectomy

Abstract

Laparoscopic partial nephrectomy has demonstrated renal functional and 5-year oncological outcomes equivalent to those of open partial nephrectomy. A remaining critique of laparoscopic partial nephrectomy is its 10-minute longer ischemia time compared to open surgery. We present an early unclamping laparoscopic partial nephrectomy technique that decreases ischemia time by more than 50%.During standard laparoscopic partial nephrectomy renal reconstruction is completely performed under ischemic conditions. In our early unclamping technique only the initial parenchymal suturing is performed under ischemia with the remainder of bolstered renorrhaphy performed in the revascularized kidney. Of 100 consecutive nonrandomized patients the initial 50 underwent standard laparoscopic partial nephrectomy (group 1) and the subsequent 50 underwent early unclamping laparoscopic partial nephrectomy (group 2).Baseline demographics (body mass index, mean tumor size and central/hilar tumor location) and intraoperative parameters (need for pelvicaliceal repair, blood loss and operative time) were similar in the groups. However, warm ischemia time was significantly lower in group 2 (31.1 vs 13.9 minutes, p <0.0001). In groups 1 and 2 ischemia time was 30 minutes or greater in 60% vs 0% of patients (p <0.0001). Compared to group 1 overall complications (22% vs 16%), postoperative renal hemorrhage (4% vs 2%) and the re-intervention rate (16% vs 6%) trended lower in group 2 (p = not significant). No patient had a positive cancer margin, required open conversion or showed renal dysfunction.This early unclamping laparoscopic partial nephrectomy technique significantly decreases ischemia time by more than 50% and also trends toward decreased complications. Our current mean ischemia time of less than 14 minutes is lower than or equivalent to that in contemporary open partial nephrectomy series.