Advantages of selective ischemia and indocyanine green fluorescence navigation in laparoscopic partial nephrectomy: preliminary results

Анотація

An important stage of the nephron-sparing surgery for the treatment of kidney tumors is the temporary creation of thermal ischemia, which can lead to a further decrease in kidney function, therefore this stage needs to be optimized. The aim of our work was to investigate the benefits of using segmental ischemia using intraoperative indocyanine green (ICG) navigation for kidney resection in patients with kidney tumors. The prospective study included 73 patients diagnosed with a kidney tumor who underwent partial nephrectomy (PN). Patients were divided into three groups, according to the use of the thermal ischemia method: total ischemia by clamping the main renal artery (n=33), segmental ischemia by clamping the segmental artery with the use of ICG navigation (n=26), and without it (n=16). Demographic, physiological, and perioperative data were analyzed for all patients. Before and on the fourth day after surgery, the glomerular filtration rate was evaluated according to the level of blood creatinine – eGFR (calculated glomerular filtration rate (eGFR). Multiple linear regression was used to model the effect of variables on change in eGFR. The data testify to the significant index difference in eGFR level change on the fourth postoperative day in the groups of total and segmental ischemia in favor of the latter (p=0.001). A decrease in eGRF was associated with the length of hospital stay (p=0.021). The data stratification in tumor size showed that it is the most important factor defining eGFR level change during total or segmental ischemia application. Renal tumor localization influences eGFR level change during the postoperative period for a maximum diameter of <40 mm tumors. However, for >40 mm diameter tumors, the statistically significant index of eGFR deviation was not found. At the same time, in the patient group with >40 mm tumors, there was a notable difference in eGFR deviation among the groups of total and segmental ischemia (about 15 mL/min/1.73 m²). In the early postoperative period (up to 4 days) after partial nephrectomy using selective warm ischemia, less pronounced eGFR deviations are observed compared to total warm ischemia. Tumor size and its localization are the risk factors for eGFR level decline in the early postoperative period. We did not find any statistically significant differences in intra- and early postoperative indexes for groups II and III patients where segmental ischemia was applied either with indocyanine green fluorescence imaging or without it.