“Crush Carving Technique” Using a Soft Coagulation Device: A Simple Method for Successful Laparoscopic Partial Nephrectomy Without Hilar Clamping

Abstract

Introduction:

According to recent studies, kidney parenchymal volume preservation was significantly associated with ultimate renal function than hilar clamping in partial nephrectomy (PN) cases. ^{1 , 2} Off-clamp PN, however, has a role for chronic kidney disease (CKD) patients, the number of which has been rising. ³ We herein describe our new method called “crush carving technique” in laparoscopic PN without hilar clamping.

Materials and Methods:

By using a unique output mode called “soft coagulation,” ⁴ we have developed a simple and novel method that can achieve both of bloodless operative field and minimal hilar clamping time during laparoscopic PN. The soft coagulation mode can automatically regulate output voltage and the kidney parenchyma can be effectively dissected according to a surgeon's planning with excellent hemostasis even without hilar clamping. Tumor resection was performed as follows: (1) the incision line was determined using intraoperative ultrasound guidance; (2) with a 0.5- to 1-cm margin from the tumor edge, we placed shallow incision of the depth within the renal cortex; (3) the deeper parenchymal area was dissected using crush carving technique with the use of a ball-shaped soft coagulation device, and the tumor was completely excised. In this study, we focused on pre-existing CKD (≥stage 3a) patients because not only remnant renal parenchyma but also reduced ischemia time appears to have a role for functional outcomes.

Results:

This case series included six patients who had an imperative indication for PN because of stage 3a CKD as a comorbidity. All patients had a complex tumor of R.E.N.A.L. nephrometry score ≥8. All surgeries using the current technique were effectively completed by a single surgeon (Y.K.) without hilar clamping with satisfactory perioperative outcomes. Decrease in estimated glomerular filtration rate was minimal and progression of CKD stage was not observed in any case.

Conclusion:

We present our new method called “crush carving technique,” which can provide both effective dissection and bloodless field in laparoscopic PN. The current technique may be useful especially in patients with pre-existing CKD.

Acknowledgments:

We thank Ms. Kyoko Komai for the narration of this video.

No competing financial interests exit.

Runtime of video: 6 mins 58 secs