Radical nephrectomy has been considered the standard treatment for localized renal cell carcinoma with normal contra-lateral kidney. Unlike radical nephrectomy, Nephronsparing surgery was usually preferred only for patients with bilateral disease, solitary functioning kidney or the abnormal opposite kidney.1-3 However, the widespread use of imaging modalities including ultrasonography, computed tomography, and magnetic resonance imaging. Consequently, such fine imaging modalities enable us to more frequently detect small-sized incidental masses and the partial nephrectomy to be more amenable.

The conventional partial nephrectomy was performed with pedicle occlusion and renal cooling achieved by ice placed on the kidney surface. However, there have been still accompanying technical difficulties in getting adequate hemostasis and a watertight closure of the collecting system with concerning about ischemic damage to the kidney. Here, we report our initial experiences of a technique of regional parenchymal compression using long curved vascular clamp without renal pedicle occlusion during open partial nephrectomy.

Nine of ten patients were presented without any symptom while one case was associated with flank discomfort and microscopic hematuria. The patients' characteristics are summarized in Table 1. The mean age was 59 years old with the range between 44 and 65 and the mean tumor size, which was determined by preoperative CT scan, was 23.8mm with the range between 12 and 55. Seven patients had a solid lesion and on the other hand, three patients had a cystic lesion. The tumors were located in the different places; 3, in the upper pole, 3 in the mid-kidney, and 4, in the lower pole. One patient (No. 6) had a solitary kidney, which resulted from the previous history of radical nephrectomy for renal cell carcinoma of right kidney and other patient (No. 8) had a small sized kidney opposite to tumor side. The rest of eight patients had a contralateral normal kidney.

Partial nephrectomy was successfully performed using parenchymal compression. The mean operative time was 110 minutes ranging from 80 and 130. Intraoperative blood loss was minimal and the mean estimated blood loss, measured by blood volume in the suction drain, was 158 with the range between 50 and 300 and, as a result, none of patients required blood transfusion postoperatively. Mean preoperative creatinine was 1.1±0.3mg/dl (range 0.8 to 1.7), postoperative 5th day's was 1.1±0.3mg/dl (range 0.7 to 1.7), and creatinine 3 months postoperatively was 1.1±0.3mg/dl (range 0.8 to 1.9). There were no differences between the preoperative and postoperative creatinine levels (p=0.936). No complication was observed, including urinary leak confirmed with closed drain or renal dysfunction during recovery period. The pathological examination was summarized in Table 2. The frozen and postoperative permanent section analysis confirmed negative margins in all patients with renal cell carcinoma. The mean follow-up of our study population was 17.2 months (range 8 to 39). No patients developed local recurrence or distant metastasis at the last follow-up.

The classic concept of surgery for renal cell carcinoma was wide excision such as radical nephrectomy due to concerns about multicentricity and local recurrence.4 Recently, many studies demonstrated that nephron sparing surgery could provide oncological results comparable to those of radical surgery for patients with smaller (less than 4cm) renal tumor.5-8 Consequently, nephron-sparing surgery has gained lots of interest as the preferred surgical management of small renal masses. The surgical options for nephron-sparing surgery are enucleation, wedge resection, segmental resections and other intervention involving cryotherapy or radiofrequency ablation.9-11 The basic principles in performing partial nephrectomy are preservation of renal function, complete tumor excision with negative surgical margins, watertight closure of the collecting system, careful hemostasis and secure closure of the renal parenchyma. Among them, careful hemostasis of resected surface is the most difficult procedure to achieve.

The hemostasis has been obtained classically by pedicle vascular occlusion and renal cooling achieved by placing ice around the renal surface. However, there were a couple of disadvantages in that procedure. First, access to renal pedicle is time-consuming and potentially dangerous. Second, due to the renal ischemia, pedicle clamping greatly limited the surgery time for a series of surgery processes such as suturing bleeding vessels and closing the collecting systems.

During the past two years, we have performed partial neprhectomy achieving local renal ischema by parenchymal compression with long curved vascular clamp and never requiring cooling the renal surface with ice slush and antiischemic prophylactic treatment. The resultant benefits were the decreasing surgery time and the smaller incision. Since localized ischemia did not affect the remainder of the renal parenchyme, we had enough time to perform hemostasis and close the collecting system without concerns about ischemic time. Furthermore, this technique is so simple that most of urologists, even inexperienced ones, can easily practice it. Up to now, we used various techniques to achieve hemostasis during partial nephrectomy, including temporary vascular occlusion, vessel suture ligation, renal compression and special surgical equipment such as the argon beam coagulator. To our knowledge, there have also been similar techniques, described by Gill et al using a tourniquet, and by Cariou and Mejean using clmaps.12-14

There were a couple of limitations in our procedure. First, in cases of hilar tumor or tumor close to the pedicle, we chose the classic technique with renal artery occlusion than our procedure. Second, the renal parenchyma was so fragile that it could be easily damaged by compression. Thus, it was very important that clamping pressure should be controlled to avoid crushing the kidney by vessel loop tied with Mosquito clamp (Fig. 1). Furthermore, there is another possible risk of the slippage of vascular clamp off the kidney. Maintaining the clamping pressure is prerequisite to prevention of the slippage and securing enough distance between clamping and incising the kidney is more essential procedure. In case of short distance between them, the vascular clamp is liable to slip off the kidney.

When any small bleeding vessels were identified after releasing the compression clamp, the additional procedures were needed to achieve hemostasis. We usually cauterized the cut surface with the argon beam coagulator and sealed with fibrin glue. The argon beam coagulator was used for hemostatic and oncologic reasons, which could easily provide a further 1mm thickness of parenchymal coagulation.15 Fibrin glue as a powerful hemostatic sealant, is utilized in various urological procedures, including pyeloplasty, urinary tract fistula treatment and open partial nephrectomy.16-19

Recently, partial nephrectomy has been regarded as the preferred surgical management of small sized renal masses. Our technique described above is so simple that it can be easily practiced by any urologic surgeon without concerns about ischemic time and complications. Taken together, localized renal parenchymal clamping is an efficient technique for open partial nephrectomy, provided tumor is located at peripheral portion of kidney.