Transperitoneal in situ intraarterial cooling in laparoscopic partial nephrectomy

Aiming the principles of open partial nephrectomy, warm ischemia time is the limiting factor especially in case of central or complex tumors in laparoscopy. We demonstrate a novel solely laparoscopic technique for in situ cold perfusion of kidneys with direct catheterization of the renal artery to increase the tolerance of renal parenchyma for ischemia.

In two patients with hilus compromising tumors, renal artery was clamped; a small incision in the artery was used to place a 5Fr centrally open angiographic balloon catheter and blocked with 1 ml NaCl. The kidney was perfused with 4°C Ringer solution. After tumor excision, the kidney was subsequently reconstructed by mattress bolster sutures and fibrin glue. The arterial incision was closed by a 4/0 Prolene suture.

Both patients had an uneventful follow-up without neither intraoperative nor postoperative complications. No intraoperative body temperature drop occurred. Cold ischemia time was 66 (men, 65a) and 60 min (women, 43a), respectively. Hemoglobin drop was 4.1 and 1.9 g/dl; no transfusion was necessary. Preoperative and postoperative creatinine levels were 0.90 and 0.76 mg/dl, and 1.3 and 0.9 mg/dl, respectively. Patients were discharged on day 12 and day 8. Histology revealed clear cell RCC (pT1b pNx pMx G2 R0) in the first patient and oncocytoma in the second patient. Postoperative CT angiograpy demonstrated no sign of arterial insufficiency.

Intraarterial renal cooling could expand the ischemia time and therefore the indication of laparoscopic partial nephrectomy in complex exposition. Furthermore, the identification of tumor borders and injured vessels is facilitated by the outflow of the cooling solution. Further investigations into this promising method could proof its feasibility in everyday clinical routine.