ERUS 2011RENAL SURGERY

COURSEBen Challacombe

Consultant Urologist & Senior LecturerGuy’s and St Thomas’ Hospitals, London

Tips to minimise warm ischaemia

WIT Why important? Time differences. 20 vs 30 vs more? Thompson RH et al ,Mayo Eur Urol. 2010.

>25 mins cutoff Becker F et al. Eur Urol. <20 mins. Choi JD Eur Urol. 2010 28 mins In a single kidney porcine model the renal

unit can fully recover from WI times of up to 90 minutes. Laven BA et al. J Urol. 2004

Thompson RH et al ,Mayo Eur Urol. 2010. Every minute counts when the renal hilum is clamped during partial nephrectomy.Becker F et al. Eur Urol. Assessing the impact of ischaemia time during partial nephrectomy.Choi JD Renal damage caused by warm ischaemia during laparoscopic and robot-assisted partial nephrectomy: an assessment using Tc 99m-DTPA glomerular filtration rate. Eur Urol. 2010

Learning curve for WIT

Bhayani SB. Robot-assisted partial nephrectomy: evaluation of learning curve for an experienced renal surgeon. J Endourol. 2010 26 cases for WIT 16 cases for OT

Mottrie A, Ficarra V. Eur Urol. 2010. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. 30 for WIT, 20 for console time

Options

Full clamping until renorrhaphy complete Early unclamping Segmental vessel clamping “zero-ischaemia” RPN No clamping

Minimising WIT

Aim for <20 mins from the start Team work vital Prior Preparation and Planning Prevents

Poor Performance Rehearse procedure Brief staff before clamping vessels

Mannitol, frusemide, clamps, sutures, control room.

Consider angles and directions of sutures Assistant to act semi- independently

Tips to keep WIT down

Needles inside before clamping Needles in correct direction of passage Deep scoring already done Posterior lip visible:

Adequate mobilisation Scanlan clips Haemostatic agent ready Don't cut sutures or add 2nd clips until

clamps off Consider early unclamping after deep suture

Scoring Kidney

Evicel

Cystic Tumour