Managing Stented Renal Arteries during Robotic-Assisted Partial Nephrectomy (Video)

By Juan D. Garisto, MD, and Jihad Kaouk, MD

When partial nephrectomy is necessary in patients with previously placed endostents for narrowing of renal arteries, it is time to “call of the dogs.” These renal stents are simply not strong enough to withstand bulldog clamps. Placing bulldogs on the artery can crush and occlude the renal artery, shutting it down permanently and damaging the kidney.

Instead, we dissect the artery more distally, at each segmental branch and use multiple bulldog clamps, successfully preserving the renal artery and kidney function.

This video demonstrates our surgical technique for robotic partial nephrectomy (RPN) with particular focus on vascular clamping in a patient with a complex renal mass and endovascular stent (ES) in the renal artery.

Background

A 73-year-old man with a 10 cm left renal and associated fenestrated endograft due to endovascular aorta repair presented to our practice. After reviewing preoperative imaging, we elected to use a robot-assisted partial nephrectomy.

Major steps included hilar control, intracorporeal renal hypothermia using ice slush, distal clamping of the renal artery, excision of renal mass, and intraoperative ultrasound post-excision to confirm blood flow.

Record review of three patients

We reviewed records of three patients who underwent RPN at our institution with selective clamping of renal arteries due to previous placement of ES to better understand outcomes. Median age was 69.6 years, BMI was 31.3, and mean eGFR was 36.6 mL/min. No cases were converted to open procedures. Perioperative outcomes of patients who underwent nephron-sparing surgery (NSS) are described in Table 1.

Our hints and tricks

Based on our review and experience, we found the following steps to be key drivers in optimizing outcomes during NSS in patients with stented renal arteries:

1. Preoperative 3D CT angiogram is crucial for surgical planning for dissection of the renal hilum.
2. An additional multiplanar volume rendering of the CT scan may allow better 3D visualization and orientation of the renal vasculature and anatomy.
3. Selective renal artery clamping distal from the renal artery stent is required to avoid renal stent occlusion.
4. Extensive and meticulous dissection of the renal hilum is mandatory for correct clamping.
5. An intraoperative Doppler ultrasound after clamping release at the end of the procedure confirms restored blood flow through the renal arteries.

Conclusion

Partial nephrectomy in patients with renal artery stents requires distal dissection of the renal artery beyond the stent. Our technique provides valuable and reproducible surgical hints and tips that will help optimize outcomes in NSS in patients with endovascular graft stents.