Hyperaccuracy Three-dimensional Reconstruction Is Able to Maximize the Efficacy of Selective Clamping During Robot-assisted Partial Nephrectomy for Complex Renal Masses

BACKGROUND: Available technologies could avoid global ischemia for the removal of a renal tumor. OBJECTIVE: To present hyperaccuracy three-dimensional (HA3D) reconstruction during robot-assisted partial nephrectomy (RAPN) and compare its efficacy in sponsoring successful selective clamping of renal arterial branches during RAPN. DESIGN, SETTING, AND PARTICIPANTS: Patients undergoing RAPN (January 2016-July 2017) for renal mass PADUA score ≥10 who underwent abdominal computed tomography scan with angiography. Since February 2017 HA3D reconstruction was performed. SURGICAL PROCEDURE: HA3D reconstruction-aided RAPN and standard RAPN with selective clamping. MEASUREMENTS: Intraoperative variables focusing on the renal arterial pedicle management and success rate of its planned management. RESULTS AND LIMITATIONS: Thirty-one patients in group no HA3D and 21 in group HA3D. The median (standard deviation) tumor size was 50.9 and 50.8mm (p=0.97), and median PADUA scores 10.5 and 11 (p=0.85) for groups no HA3D and HA3D, respectively. In group no HA3D, a significantly higher number of patients underwent global ischemia (80% vs 24%, p<0.01). Of note, in 90% of the group HA3D cases, intraoperative management of the renal pedicle was performed as preoperatively planned; in 39% of the group no HA3D cases, management of the renal arterial pedicle was varied intraoperatively (p=0.04). We disclose the limited sample size and the experimental technique. CONCLUSIONS: Preoperative simulation of selective ischemia was feasible and effective with HA3D reconstruction. In all the RAPN cases performed, selective clamping was successful, avoiding ischemia of the healthy renal remnant. A strict collaboration between urologists and bioengineers is mandatory to improve the technology. PATIENT SUMMARY: In this report, we found that an accurate three-dimensional reconstruction of the kidney before conservative surgery for renal cancer seems to help in avoiding the global ischemia of the kidney. Further studies are needed to conclude if avoiding a percentage of ischemia to the kidney is clinically relevant.