RU2841910C1 - Method for anti-ischemic protection of kidney parenchyma during laparoscopic resection - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to urology and oncology. Renal artery and vein are approached. Rubber tourniquet with size of 0.4×0.2×10 cm is brought and fixing tube 1.5-2 cm long into the abdominal cavity through 12 mm trocar opening. Loop around the renal artery is formed with a rubber tourniquet. Tourniquet ends are delivered into the fixing tube. Tourniquet is pulled on, and the visually aided renal artery is occluded by the tourniquet with tightening the arterial walls around the retrieval catheter. After the tourniquet is pulled, a vascular bulldog-type clamp is applied on the rubber tourniquet at a proximal end of the fixing tube. Time of ischemia onset is recorded. Isotonic 0.9% sodium chloride solution cooled to +4 °C is administered through a balloon catheter. Renal perfusion is carried out without blocking venous outflow with preservation of blood contained in parenchyma kidney 150-250 ml, wherein distal end of endovascular catheter is in distal portion of segmental branch of renal artery. Rubber tourniquet is applied in a proximal portion of the renal artery. Upon reaching 300 ml of supplied 0.9% normal saline solution, a vascular clamp is applied to the renal vein and in the case of a surgical intervention on the left kidney, the left gonadal vein is transected at distance of 4 cm from the confluence point; right kidney surgery involves forming a defect of diameter of 1 mm in an anterior wall of a right renal vein. A kidney is temporarily excluded from a main blood flow. Kidney tumour is removed. After the resection stage is completed, the kidney wound is closed. Blood flow is started. That is followed by an electric coagulation of the left gonadal vein or an anterior wall of the right renal vein. Renal vein is clamped, and the rubber tourniquet is loosened. If observing a satisfactory haemostasis, the rubber tourniquet and the endovascular catheter are removed.

EFFECT: method provides anti-ischemic protection of the kidney with its temporary disconnection from the main blood flow during its resection; reduce the risk of renal dysfunction after the partial nephrectomy, and also reduce the risk of damage to the renal artery; to reduce risk of the complications connected with long-term thermal ischemia, and also volemic, metabolic and hypothermic complications.

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Description

The invention relates to the field of medicine, namely to urology and oncology, and can be used in the surgical treatment of patients with malignant and benign kidney tumors.

The "gold standard" of treatment of patients with kidney tumors up to 0 cm is partial nephrectomy when technically possible. Development of surgical techniques allowed performing partial nephrectomy even with larger tumor sizes (7 cm and more). Minimally invasive surgical approaches (laparoscopic and robotic) have become generally accepted compared to open surgery. Nephron-sparing operations are usually performed in case of warm ischemia, which is a risk factor for chronic kidney disease (CKD) due to reperfusion injury of the renal parenchyma after restoration of blood flow. The generally accepted interval of safe warm ischemia of the kidney is up to 20-30 minutes. However, in case of planned complex resection with a longer warm ischemia time or with initially reduced renal function, prevention of renal dysfunction is necessary.

A method of robotic partial nephrectomy with intracorporeal renal hypothermia using ice slush is known (JH K., D S., J K., et al. Robotic partial nephrectomy with intracorporeal renal hypothermia using ice slush // Urology. 2014. No. 3 (84). P. 712–718). The kidney is covered with ice chips or an ice-cold saline solution is used.

The disadvantage of this method is that the temperature in the center of the kidney is still not low enough and there is a risk of damage to the renal parenchyma (temperature gradient due to surface cooling). The technique is labor-intensive, and ice chips getting on the intestines can lead to severe postoperative paresis; there is also an increased risk of renal artery thrombosis.

A method of retroperitoneoscopic partial nephrectomy with transient occlusion of the renal artery for the treatment of small renal tumors is known (Matsuda T., Nakagawa M., Oguchi N., et al. Retroperitoneoscopic partial nephrectomy with transient occlusion of renal artery for the treatment of small renal tumors // Urology. 2004. No. 1 (64). P. 26–30). Perfusion of cooled saline solution is performed through the upper urinary tract using a ureteral catheter.

The disadvantage of this method is low cooling efficiency.

A method of cold intravascular organ perfusion for renal hypothermia during laparoscopic partial nephrectomy is known (Marley CS, Siegrist T, Kurta J, O'Brien F, Bernstein M, Solomon S, Coleman JA. Cold intravascular organ perfusion for renal hypothermia during laparoscopic partial nephrectomy. J Urol. 2011 Jun;185(6):2191-5). Perfusion of cooled saline solution is performed through the renal artery by its direct cannulation. The essence of the method consists in direct cannulation of the renal artery with its proximal clamping and subsequent introduction of cooled Ringer's solution 20°C into the kidney, without affecting the renal vein, in order to ensure the outflow of the administered solution.

The disadvantage of this method is the complex and labor-intensive system of delivering the cooled solution through a 431 cm long tube, which is additionally cooled in cold water baths at 0°C and introduced into the abdominal cavity through one laparoscopic trocar, as well as the disruption of the integrity of the renal artery by direct puncture with a 21G needle. Another disadvantage is the need for intraoperative body temperature monitoring using transesophageal thermometry, since the solution enters the systemic bloodstream.

A method of extracorporeal partial nephrectomy for pharmaco-cold ischemia of renal cell carcinoma is known (Gritskevich A.A., Miroshkina I.V., Piyanikin S.S., et al. Extracorporeal partial nephrectomy under pharmaco-cold ischemia for renal cell carcinoma // Khirurgiia. 2017. No. 1. P. 42–47). The technique involves performing a nephrectomy, perfusing the kidney with a cooled solution, and removing the tumor, followed by orthotopic or heterotopic kidney transplant.

The disadvantages of the technique are its labor intensity, complete intersection of the renal vessels and, as a consequence, an increased risk of vascular thrombus formation after kidney transplantation.

A method of preoperative catheterization of the renal artery in an X-ray surgical operating room with subsequent intraoperative perfusion of the kidney with a cooled solution is known (Maksimov A.V., Martov A.G., Neustroev P.A. et al. Kidney tumor resection with superselective balloon targeted chemoembolization. Oncourology 2020; 16 (4): 49–58). The method solves the problem of achieving a sufficiently low temperature in the center of the kidney, thereby reducing the risk of renal dysfunction.

However, during patient transportation from the catheter room to the main operating room, there is a high risk of balloon catheter migration from the renal artery. The study describes that when the catheter migrates, the patient is again transported to the catheter room for repositioning the distal tip of the balloon catheter, which increases the cost of treatment and increases the risks of bleeding and infectious complications. Also, blocking the renal blood flow with a balloon catheter can cause dissection and rupture of the renal artery, which requires preoperative assessment of the renal artery diameter using multispiral computed tomography of the abdominal organs with intravenous contrast enhancement and intraoperative measurement of the diameter using direct angiography and selective selection of the balloon catheter diameter [Liu F., Yuan H., Li X., et al. Application of Hypothermic Perfusion via a Renal Artery Balloon Catheter During Robot-assisted Partial Nephrectomy and Effect on Renal Function // Academic radiology. 2019. No. 8 (26). [C. e196–e201].

The closest (prototype) is the method of anti-ischemic protection of the renal parenchyma during laparoscopic resection (RU 2793505 C2). Access to the left renal artery, vein and gonadal vein is performed, then a vascular clamp is applied to the renal vein, which is distinguished by the fact that a double-lumen balloon catheter is simultaneously inserted into the lumen of the diagnostic catheter previously installed in the renal artery, which occludes the renal artery. Next, the left gonadal vein is crossed and isolated perfusion of the kidney is performed until the blood contained in it is completely washed out, using 0.9% isotonic sodium chloride solution as a cooled solution, after which the kidney is resected.

However, this method has a number of disadvantages: the complexity of the technique (it is necessary to X-ray control the position of the balloon catheter after transportation from the X-ray operating room, when turning the patient on his side and directly when positioning the balloon. During control, it is necessary to administer a contrast agent. All this increases the radiation load on the patient, causes damage to the kidneys with a radiopaque agent, increases the cost, increases the labor intensity of the operation, dictates the need to provide the laparoscopic operating room with an X-ray unit. Another significant disadvantage of this technique is the risk of dissection and rupture of the renal artery during positioning of the balloon catheter, since this method does not imply visual control of the degree of occlusion of the artery. Insufficient inflation of the balloon can lead to parenchymal bleeding, while excessive inflation - to rupture of the renal artery.

The technical solution of the invention is to reduce the risk of renal dysfunction after kidney resection, as well as to reduce the risk of damage to the renal artery.

The specified technical and therapeutic results in the implementation of the invention are achieved due to the fact that, just as in the known method, access is gained to the renal artery and vein, then a vascular clamp is applied to the renal vein.

The peculiarity of the claimed method is that it is distinguished by the fact that

a rubber tourniquet measuring 0.4x0.2x10 cm and a fixing tube 1.5-2 cm long are inserted into the abdominal cavity through a 12 mm trocar opening,

a rubber tourniquet is used to form a loop around the renal artery,

the ends of the turnstile are inserted into the fixing tube,

the tourniquet is pulled tight and under visual control the renal artery is occluded by the tourniquet, tightening the walls of the artery around the endovascular catheter,

after tensioning the tourniquet, a vascular clamp of the “Bulldog” type is applied to the rubber tourniquet at the proximal edge of the fixing tube,

the time of the onset of ischemia is recorded,

then, through a balloon catheter, an isotonic solution of 0.9% sodium chloride cooled to +4°C is administered,

perfusion of the kidney is carried out without blocking the venous outflow while maintaining the blood contained in the renal parenchyma at 150-250 ml,

in this case, the distal end of the endovascular catheter is located in the distal part of the segmental branch of the renal artery,

a rubber tourniquet is applied to the proximal part of the renal artery, then, upon reaching 300 ml of the supplied 0.9% isotonic sodium chloride solution, a vascular clamp is applied to the renal vein and:

in case of surgical intervention on the left kidney, the left gonadal vein is crossed at a distance of 4 cm from the site of confluence;

in case of surgical intervention on the right kidney, a defect with a diameter of 1 mm is formed in the anterior wall of the right renal vein;

then the kidney is temporarily “switched off” from the main blood flow,

the kidney tumor is removed and, after the resection stage is completed, the kidney wound is sutured and blood flow is started,

electrocoagulation of the left gonadal vein or suturing of the anterior wall of the right renal vein is performed,

The clamp is removed from the renal vein and the rubber tourniquet is loosened; if hemostasis is convincing, the rubber tourniquet and endovascular catheter are removed.

The invention is explained by a detailed description, a clinical example and illustrations, which depict:

Fig. 1 – diagram of the location of the tumor in the middle third of the left kidney.

Fig. 2 - diagram of the stage of endovascular access to the segmental branch of the renal artery and the application of a rubber tourniquet to the renal artery and a vascular clamp to the renal vein.

Fig. 3 - photo illustration of the location of the endovascular catheter in the segmental branch of the renal artery: a) the endovascular catheter is inserted into the proximal part of the renal artery; b) the endovascular catheter is inserted into the distal part of the upper segmental branch of the renal artery.

Fig. 4 – photo illustration of the isolated left renal artery and vein and the application of a rubber tourniquet to the renal artery and a vascular clamp to the renal vein.

Fig. 5 – diagram of the liquid flow when using a rubber tourniquet.

Fig. 6 - photo illustration of a stage of resection of the left kidney.

Fig. 7 - photo illustration of the final appearance: the wound of the left kidney is sutured.

Fig. 8 – diagram of the sutured wound of the left kidney: the endovascular catheter has been removed.

Fig. 9 - photo illustration of the final appearance: the renal parenchyma is supplied with blood.

The method is performed as follows.

The first step after intubation of the patient in the supine position with the arm abducted at 90° at the level of the upper third of the shoulder is to perform a puncture of the brachial artery using the Seldinger method under ultrasound control. A hydrophilic introducer is installed in the brachial artery. A Cobra° endovascular catheter with a diameter of 7Fr, a length of 110 cm, and an internal lumen of 1.5 mm (0.038 inches) is inserted through the introducer. A guidewire with a J-shaped bend at the distal end with a radius of 0.97 mm (0.038 inches) is inserted through the catheter. Under X-ray control with the introduction of a radiopaque non-ionic iodine-containing substance, the distal end of the endovascular catheter is inserted into the renal artery and then into the maximum possible distal part of the segmental renal artery. The introducer and catheter are fixed to the arm (Fig. 3 a, b).

The patient is then transported to the operating room, which is equipped with a stand for laparoscopic surgery.

In the operating room, the patient is repositioned on his side with his arm fixed on the operating table holder. Using a Veress needle, carboxyperitoneum (12 mm Hg) is applied. A video trocar and three trocars for instruments are installed: in the subcostal, mesogastric and iliac regions.

Access to the renal artery and vein is obtained. A rubber tourniquet and a fixing tube are inserted into the abdominal cavity through a 12 mm trocar opening. The dimensions of the rubber tourniquet are 0.4 x 0.2 x 10 cm. A fragment of a single-lumen drainage tube 1.5-2 cm long is used as a fixing tube. A loop is formed around the renal artery with the rubber tourniquet, the ends of the tourniquet are inserted into the fixing tube, the tourniquet is pulled tight and, under visual control, the renal artery is occluded with the tourniquet, pulling the artery walls together around the endovascular catheter. After the tourniquet is pulled tight, the fixing tube is installed using a “Bulldog” vascular clamp, which is applied to the rubber tourniquet at the proximal edge of the fixing tube in order to maintain the tension of the tourniquet (Fig. 2, Fig. 4).

The onset time of ischemia is recorded. Next, an isotonic 0.9% sodium chloride solution cooled to +4°C is administered through the catheter. The kidney is perfused without blocking the venous outflow in order to preserve the blood contained in the renal parenchyma (150-250 ml) and “wash it out” into the main channel. In this case, the distal end of the endovascular catheter is in the distal section of the segmental branch of the renal artery, and a rubber tourniquet is applied in the proximal section of the renal artery. Thus, when the cooled solution is administered, the pressure in the entire arterial system of the kidney is equalized, ensuring uniform perfusion of the entire thickness of the renal parenchyma (Fig. 5).

Once 300 ml of 0.9% isotonic sodium chloride solution is supplied, a vascular clamp is applied to the renal vein and:

- in case of surgical intervention on the left kidney - the left gonadal vein is transected. In this case, the transection is performed at a distance of at least 4 cm from the confluence site in order to facilitate subsequent coagulation of the inflow stump;

- in case of surgical intervention on the right kidney - a defect up to 1 mm in size is formed along the anterior wall of the right renal vein. The kidney is temporarily “switched off” from the main blood flow, which makes it possible to perform the resection stage for a long time without the risk of loss of kidney function and parenchymal bleeding. The kidney tumor is removed (Fig. 5, Fig. 6). After the resection stage is completed, the kidney wound is sutured and the blood flow is started. Electrocoagulation of the tributaries of the renal vein or suturing of its anterior wall is performed alternately, the clamp is removed from the renal vein and the rubber tourniquet is loosened. In case of convincing hemostasis, the rubber tourniquet and endovascular catheter are removed (Fig. 7, Fig. 8).

Thus, the developed method of anti-ischemic protection of the kidney during its temporary disconnection from the main blood flow during its resection provides the possibility of long-term intracorporeal disconnection, which reduces the risk of complications associated with prolonged warm ischemia, as well as volemic, metabolic and hypothermic complications that develop when performing cold ischemia using other methods, and also reduces the risk of damage to the renal artery, which is not cannulated, and injury from dilation is excluded.

Clinical example of implementation No. 1.

Patient K., 37 years old. Admitted to the urology department of the P.A. Herzen Moscow Oncology Research Institute - branch of the National Medical Research Center of Radiology of the Ministry of Health of the Russian Federation with a clinical diagnosis of "Left kidney cancer stage I. cT1aN0M0". On 04.04.2024, surgical intervention was performed in the volume of laparoscopic resection of the left kidney with intra-arterial cold perfusion (R.E.N.A.L 11).

In the supine position with the left arm abducted at 90°, at the level of the upper third of the shoulder, under ultrasound control, a puncture of the left brachial artery was performed using the Seldinger method. A hydrophilic introducer with a diameter of 7Fr (2.3 mm) and a length of 11 cm was inserted into the left brachial artery. A Cobra° endovascular catheter with a diameter of 7Fr and a length of 110 cm with an internal lumen of 1.5 mm (0.038 inches) was inserted through the introducer. A guidewire with a J-shaped bend at the distal end with a radius of 0.97 mm (0.038 inches) was inserted through the catheter. Under X-ray control with the introduction of a non-iodinated radiopaque substance, the distal end of the endovascular catheter was inserted into the distal section of the upper segmental branch of the left renal artery (Fig. 2).

The patient was taken from the X-ray room to the operating room equipped with a laparoscopic stand, where she was repositioned in a right lateral decubitus position. In the area of the lateral edge of the rectus abdominis muscle on the left at a level of 2 cm above the umbilicus, a puncture of the abdominal wall was made with a Veress needle, carboxyperitoneum of 12 mm Hg was applied. A trocar with a laparoscope was inserted at the same point. Three instrumental trocars were installed under visual control: 5 mm in the left hypochondrium along the midclavicular line, 10 mm in diameter in the iliac region on the left along the midclavicular line, 5 mm in the left mesogastric region along the anterior axillary line. The left kidney was mobilized along the medial and lateral surfaces. Intraoperative ultrasound was performed. On the anterior surface of the kidney, in the sinus area, completely intraparenchymatous, a tumor formation is determined, up to 22 mm in size, intimately adjacent to the left renal vein and segmental arteries (Fig. 1). The left renal artery and vein, gonadal vein are isolated (Fig. 3). A rubber tourniquet is applied to the left renal artery. The tourniquet is tightened and fixed, occluding the artery around the endovascular catheter previously installed in the left renal artery (Fig. 4). Washing of the left kidney with cooled (+ 4°C) physiological solution of 0.9% sodium chloride is started, perfusion of the kidney is performed without blocking the venous outflow while preserving 250 ml of blood contained in the renal parenchyma. Upon reaching 300 ml of the supplied solution, a vascular clamp is applied to the renal vein. The left gonadal vein draining into the left renal vein was transected at a distance of 4 cm from the site of its confluence with the left renal vein. Cooled fluid was drained through it. With technical difficulties (the tumor node involved the wall of the renal vein without signs of true invasion), the left kidney was resected within the healthy tissues using the Harmonic Ace apparatus and cold scissors (Fig. 5, Fig. 6). The kidney wound was sutured with a continuous two-row atraumatic suture and fixed using the sliding clip technique. The area of the confluence of the left testicular vein into the left renal vein was treated with bipolar coagulation, the clamp was removed from the left renal vein. Tension was removed from the rubber tourniquet. The kidney acquired a characteristic color, hemostasis is convincing. (Fig. 9) The cold ischemia time was 70 minutes. Endovascular catheters were removed from the brachial artery after completion of the main surgical stage (Fig. 7, Fig. 8). The resection area was treated with surgical glue. Hemostasis was dry. The integrity of the paranephric tissue was restored. An insurance drainage was installed to the resection area.

Clinical example of implementation No. 2.

Patient S., 42 years old. Admitted to the urology department of the P.A. Herzen Moscow Oncology Research Institute, a branch of the National Medical Research Center of Radiology of the Ministry of Health of the Russian Federation, with a clinical diagnosis of "Right kidney cancer, stage I. cT1bN0M0". On July 11, 2024, a surgical intervention was performed in the amount of laparoscopic resection of the right kidney with intra-arterial cold perfusion (R.E.N.A.L 11). In the supine position with the left arm abducted at 90°, at the level of the upper third of the shoulder, a puncture of the left brachial artery was performed using the Seldinger method under ultrasound control. A hydrophilic introducer with a diameter of 7Fr (2.3 mm) and a length of 11 cm was inserted into the left brachial artery. A Cobra° endovascular catheter with a diameter of 7Fr and a length of 110 cm with an internal lumen of 1.5 mm (0.038 in) was inserted through the introducer. A guidewire with a J-shaped bend at the distal end with a radius of 0.97 mm (0.038 in) was inserted through the catheter. Under radiological control with the introduction of a radiopaque non-iodinated substance, the distal end of the endovascular catheter was inserted into the distal part of the lower segmental branch of the right renal artery. The patient was taken from the X-ray room to the operating room equipped with a laparoscopic stand, where she was repositioned into a left lateral position. In the area of the lateral edge of the rectus abdominis muscle on the right at a level of 2 cm above the umbilicus, a puncture of the abdominal wall was made with a Veress needle, carboxyperitoneum of 12 mm Hg was applied. A trocar with a laparoscope was inserted at the same point. Three instrumental trocars were installed under visual control: 10 mm in the right hypochondrium along the midclavicular line, 5 mm in diameter in the iliac region on the right along the midclavicular line, 5 mm in the right mesogastric region along the anterior axillary line. The right kidney was mobilized along the medial and lateral surfaces. A tumor formation up to 72 mm in size was determined along the posterior surface of the kidney, in the area of the lower pole. The right renal artery and vein were isolated. A rubber tourniquet was applied to the right renal artery. The tourniquet is tightened and fixed, occluding the artery around the endovascular catheter previously inserted into the right renal artery. The right kidney is flushed with cooled (+4°C) 0.9% saline solution, the kidney is perfused without blocking the venous outflow while preserving 150 ml of blood contained in the renal parenchyma. Upon reaching 300 ml of the supplied solution, a vascular clamp is applied to the renal vein. The right renal vein is incised along the anterior surface. The defect diameter is 1 mm. Cooled fluid is drained through it. With technical difficulties (the tumor node protrudes into the sinus), resection of the right kidney within healthy tissues was performed using the Harmonic Ace apparatus and cold scissors. The kidney wound was sutured with a continuous two-row atraumatic suture with fixation using the sliding clip technique. The supply of cooled solution was stopped. The defect in the renal vein was sutured with Prolen 5.0 thread, the clamp was removed from the right renal vein. Tension was removed from the rubber tourniquet. The kidney acquired a characteristic color, hemostasis is convincing. The cold ischemia time was 75 minutes. Endovascular catheters were removed from the brachial artery after completion of the main surgical stage. The resection area was treated with surgical glue. Hemostasis is dry. The integrity of the paranephric tissue was restored. An insurance drainage was installed to the resection area.

Thus, the developed method of anti-ischemic protection of the kidney during its temporary disconnection from the main blood flow during its resection provides the possibility of long-term intracorporeal disconnection, which reduces the risk of complications associated with prolonged warm ischemia, as well as volemic, metabolic and hypothermic complications that develop when performing cold ischemia using other methods, and also reduces the risk of damage to the renal artery, which is not cannulated, and injury from dilation is excluded.

When implementing this method, there is no need to control the position of the endovascular catheter, since its distal fragment is inserted into the distal section of the segmental branch of the renal artery, which eliminates/reduces the risk of its excessive migration into the aorta.

The proposed method allows to reduce the radiation load on the patient, reduce the toxic effect of the radiopaque agent, as well as the labor intensity of its use in general, since it eliminates the need to equip the operating room with an X-ray unit, which significantly reduces the financial burden on the hospital. Performing artery occlusion with a rubber tourniquet, compared with using an expensive balloon catheter, also reduces the financial burden on the medical institution, reduces the total time spent on surgical intervention, and, most importantly, is much safer, since artery occlusion is performed under visual control. The rubber tourniquet gently compresses the renal artery around the endovascular catheter, which prevents its damage.

Claims (4)

A method for anti-ischemic protection of the renal parenchyma during laparoscopic resection, including access to the renal artery and vein with subsequent application of a vascular clamp to the renal vein, characterized in that a rubber tourniquet measuring 0.4 × 0.2 × 10 cm and a fixing tube 1.5-2 cm long are inserted into the abdominal cavity through a 12 mm trocar opening, a loop is formed around the renal artery with the rubber tourniquet, the ends of the tourniquet are inserted into the fixing tube, the tourniquet is pulled and, under visual control, the renal artery is occluded with the tourniquet, tightening the walls of the artery around a search catheter, after pulling the tourniquet, a vascular clamp of the "Bulldog" type is applied to the rubber tourniquet at the proximal edge of the fixing tube, the time of ischemia onset is recorded, then an isotonic sodium solution cooled to + 4 ° C is administered through a balloon catheter chloride 0.9%, perfusion of the kidney is carried out without blocking the venous outflow while maintaining the blood contained in the renal parenchyma 150-250 ml, while the distal end of the endovascular catheter is in the distal section of the segmental branch of the renal artery, a rubber tourniquet is applied in the proximal section of the renal artery, then upon reaching 300 ml of the supplied isotonic solution of sodium chloride 0.9%, a vascular clamp is applied to the renal vein and in case of surgical intervention on the left kidney, the left gonadal vein is crossed at a distance of 4 cm from the site of confluence; in case of surgical intervention on the right kidney, a defect with a diameter of 1 mm is formed in the anterior wall of the right renal vein; then the kidney is temporarily "switched off" from the main blood flow, the kidney tumor is removed and after the resection stage is completed, the kidney wound is sutured and the blood flow is started, electrocoagulation of the left gonadal vein or suturing of the anterior wall of the right renal vein is performed, the clamp is removed from the renal vein and the rubber tourniquet is loosened, if hemostasis is convincing, the rubber tourniquet and endovascular catheter are removed.