RU2812295C1 - Method of organ-preserving robot-assisted intracorporal kidney resection using isolated pharmaco-cold ischemia with cardioplegic solution - Google Patents

Abstract

FIELD: medicine; urology; surgery; oncology.

SUBSTANCE: following is performed: ports for carrying out robotic manipulators are installed, transperitoneal access to the kidney is made by opening the retroperitoneal space along the Toldi line, the kidney is mobilized, the kidney tumor is identified, the kidney is isolated along the renal vein, renal artery and ureter, the kidney is rotated, vascular clamps are installed like a “bulldog” on the branches of the renal artery and vein, followed by resection of the kidney tumor, removal of clamps, followed by drainage of the retroperitoneal space and restoration of the integrity of the retroperitoneal space. Before tumor resection, pharmaco-cold ischemia of the kidney is performed using Custodiol cardioplegic solution. For this purpose, simultaneously with the installation of ports for carrying out robotic manipulators, an additional port for carrying out an endoscopic injector is installed. For pharmaco-cold ischemia of the kidney, a venotonic opening is formed in the wall of the renal vein distal to the place of its clamping. The blood is aspirated, the renal artery is punctured with an endoscopic injector distal to the clamping site, and perfused with Custodiol cardioplegic solution. After removing the tumor within healthy tissue and removing the vascular clamp from the renal artery and kidney hyperemia, the residual volume of the cardioplegic solution is aspirated from the blood through the renal vein. Then the hole in the renal vein is sutured, and the vascular clamp is removed from the renal vein.

EFFECT: method provides the possibility of long-term, up to 180 minutes, disconnection of the kidney from the main blood flow during robotic interventions on it while reducing intraoperative and postoperative risks, can significantly reduce the trauma of the operation and the amount of blood loss, and allows the patient to be quickly activated in the postoperative period on the 1st day after surgery, remove the safety drainage and urethral catheter at an earlier date, and discharge the patient 4–5 days after the surgery.

1 cl, 3 dwg, 3 ex

Description

Field of technology to which the invention relates

The invention relates to the field of medicine, namely to urology, surgery and oncology, and can be used when performing robot-assisted intracorporeal resections of large, intraparenchymal, centrally located and multiple kidney tumors using pharmaco-cold ischemia with a cardioplegic solution (“Custodiol”). The claimed method makes it possible to carry out organ-preserving surgical treatment for traumatic kidney resections in conditions of prolonged ischemia with the possibility of restoring damaged structures of the vascular and collecting systems of the kidney.

State of the art

According to world statistics, kidney malignancy (MKT) is one of the most common oncological diseases. In 2020, GNP took 14th place in the structure of morbidity for both sexes. 431,288 cases were identified. The occurrence of this pathology is more common in men (271,249 thousand cases) than in women (160,039 thousand cases). 179,368 thousand deaths from this pathology have been registered. (Information is presented according to the World Health Organization for 2020, http://gco.iarc.fr/today (accessed May 12, 2023). In Russia, this problem is even more relevant. In 2021, kidney cancer took 10th place in the structure of cancer incidence of both sexes (3.8%), 22,010 cases of newly diagnosed malignant kidney tumors were registered. In the age group under 30 years and from 30 to 59 years, kidney cancer ranks 9th among all oncological pathologies and accounts for 3.2% and 4.4%, respectively. The average age of a patient with a newly diagnosed malignant neoplasm in Russia is 64 years. The increase in incidence over the past 10 years was 13.97%, with an annual increase of 1.3% [Malignant neoplasms in Russia in 2021 ( morbidity and mortality), Edited by A.D. Kaprin, V.V. Starinsky, A.O. Shakhzadova - M.: P.A. Herzen MNIOI - branch of the Federal State Budgetary Institution "National Medical Research Center of Radiology" of the Ministry of Health, Russia, - 2022 . - ill. - 252 p.].

As a result of timely diagnosis and treatment, over the past 10 years there has been a trend in the reduction of deaths as a result of GNP.

According to clinical guidelines, the most effective treatment for localized renal cell carcinoma (RCC) is partial nephrectomy (RP) or radical nephrectomy (RN) [Clinical guidelines of the Ministry of Health of the Russian Federation, Renal parenchymal cancer, 2021].

For localized forms of kidney tumors, the “gold standard” of treatment is organ-preserving surgery - kidney resection. However, when the tumor is located intrarenally (RENAL 7 and higher), its invasion into the calyces and sinus of the kidney, such surgical interventions are technically very difficult, and urologists in such cases often resort to nephrectomy.

The advantage of nephron-sparing operations (resections) is the possibility of maximally preserving the functioning renal parenchyma, which significantly reduces the likelihood of the patient developing cardiovascular complications and improves his quality of life in the absence of differences in the oncological results of RP compared to RN.

The possibility of performing RP is determined by the size and location of the tumor. Performing an organ-sparing operation involves clamping the renal vascular pedicle, which leads to temporary ischemia of the kidney and increases the risk of developing ischemic and reperfusion complications; accordingly, the more complex the tumor, the longer the ischemia time for the possibility of its radical resection.

Today, there are various methods of surgical treatment for kidney resection, both intracorporeal, extracorporeal, and mixed. At the same time, there is currently no consensus regarding the indications for anti-ischemic protection measures during RP. In the domestic and foreign literature, there is insufficient data on a comparative analysis of the immediate and long-term results of organ-saving operations. The effect of pharmaco-cold ischemia on the functional state of the kidney in the early and late postoperative period remains unclear.

The claimed method makes it possible to preserve the organ in case of a complex tumor location, multiple neoplasms and neoplasms in a single (or only functioning) kidney, as well as significantly reduce the consequences of ischemic and reperfusion complications. The claimed method is based on the use of a robot-assisted system, which allows minimizing access trauma, improving visualization, reducing intraoperative blood loss, and also precision tumor removal completely intracorporeally.

There is a known method of endovideosurgical kidney resection and radical nephrectomy in the process of laparoscopic and robot-assisted operations, based on the safe isolation of the vessels of the renal pedicle (RF patent No. 2742367, published 02/05/2021), which includes isolation of the lower pole of the kidney with further traction of the kidney by the fascia Herotas upward towards the lateral abdominal wall using a clamp. Dissection is carried out to the lumbar muscle of the mentioned triangular-shaped area, limited by anatomical landmarks: on the one hand, by the medial edge of the kidney, on the other hand, cranially, by the renal vein, and on the third side, by the gonadal vein, and removal of perinephric tissue from it. This method makes it possible to increase safety and technically simplify the isolation of vessels of the renal pedicle during endovideosurgical resection of the kidney and radical nephrectomy during laparoscopic and robot-assisted operations, as well as minimize the risk of complications and reduce the duration of the operation. The disadvantage of this known method is the inability to carry out intracorporeal perfusion with central and intraparenchymal tumor localization, as well as large and multiple tumors with a long period of ischemia, which can lead to the development of adverse events, such as kidney necrosis due to a long ischemia time. In addition, this method solely describes the isolation of the vascular pedicle without a detailed description of the nephrectomy itself.

It is known from the prior art to perform organ-preserving operations during kidney resection using pharmaco-cold ischemia with the cardioplegic solution “Custodiol” (invention patent RU2595060; Komyakov B.K., Shlomin V.V., Guliev B.G., Zamyatnin S.A. , Tovstukha D.V., Nechaev I.I. Kidney resection for cancer in conditions of prolonged cold ischemia // Medical Bulletin of Bashkortostan. 2013. Vol. 8, No. 2: pp. 302-304.) The methods described in publications provide the possibility of long-term intracorporeal isolation of the left kidney from the main bloodstream during surgical interventions on it due to long-term perfusion with a cooled cardioplegic solution, which reduces the risk of complications associated with the need for autotransplantation of the left kidney, as well as volemic, metabolic and hypothermic complications that develop during prolonged isolation of the left kidney from the main blood flow during surgical treatment of her diseases. The disadvantage of the known methods is to provide access to the kidney through open surgery (lumbotomy) to carry out all the necessary manipulations for its perfusion. This approach is significantly more traumatic for the patient in terms of the volume of the surgical wound, is associated with a greater volume of intraoperative blood loss, a longer hospital postoperative period and a higher risk of developing postoperative complications than the minimally invasive robotic or laparoscopic approach used in the present invention.

There is a known method for in situ kidney resection in a child under cold perfusion conditions for nephroblastoma (invention patent RU2775881). The method is carried out as follows. The kidney is isolated, the renal artery and vein and the abdominal aorta are mobilized in the projection of the orifice of the renal artery. In this case, the renal vessels are hung on tourniquets, and a purse-string suture is placed on the aorta. In the center of the purse-string suture, puncture catheterization is performed with a 16G port, followed by insertion of the catheter into the renal artery. A vascular clamp is placed on the distal part of the renal vein. Lateral to the applied vascular clamp, a 3 mm incision in the renal vein is made. The kidney is covered with sterile ice. A cooled solution of Custodiol is injected into the kidney through the catheter, the kidney is perfused for 10 minutes, and then the stage of kidney resection is performed. A ureteral stent is installed through the access in the pelvis, the renal parenchyma is sutured, and hemostasis is performed. The ice is removed, the vein is sutured in the transverse direction with Prolen 6.0. The vascular clamp is removed from the renal vein, and the tourniquet placed on the renal artery is removed. The blood flow is resumed, after which the catheter is removed from the aorta, the cannulated hole in the aorta is sutured with a purse-string suture, and the wound is sutured layer-by-layer. The method makes it possible to provide the necessary conditions for cold perfusion during surgical removal of a tumor of the left or right kidney with a minimal risk of developing postoperative complications, as well as to achieve good immediate and long-term results of surgical treatment. However, the known method also uses open surgical access to the kidney (lumbotomy) to carry out all the necessary manipulations for its perfusion. This approach is significantly more traumatic for the patient in terms of the volume of the surgical wound, which is associated with a large volume of intraoperative blood loss, a long hospital postoperative period and a higher risk of developing postoperative complications, compared to the minimally invasive robotic or laparoscopic approach used in the claimed invention.

The closest to the claimed invention is the method of robot-assisted laparoscopic partial nephrectomy: step-by-step contemporary technique and surgical outcomes at a single high-volume institution. Eur Urol. 2012;62(3):553-61. doi: 10.1016/j.eururo.2012.05.021.], according to which the patient is placed in the Trendelenburg position, followed by the installation of four robotic ports to implement transperitoneal access, followed by gas insufflation into the abdominal cavity. An Allis clamp is applied to atraumatically capture and retract the liver. The retroperitoneal space is opened along Toldi's line. The intestine is mobilized medially, creating a plane anterior to Gerota's fascia and posterior to the mesentery of the colon using sharp and blunt dissection techniques. Dissection is performed to the psoas muscle. Bulldog clamps are applied to the vessels of the renal pedicle, and then the tumor is excised. To do this, Gerota's fascia is opened in an area distant from the tumor, followed by dissection until direct visualization of the tumor is achieved. An ultrasound sensor is used to determine the tumor boundary. The resection margins are marked using cauterization. Next, tumor resection is performed, followed by removal of the clamps from the renal pedicle. The tumor mass is removed from a mini-access. The disadvantages of this known method is the impossibility of implementing the method under conditions of prolonged renal ischemia.

The technical problem solved by the claimed invention is to provide anti-ischemic protection of the kidney in the conditions of a robotic approach when performing resection of large and/or multiple tumors of various locations (including intraparenchymal and central), tumors of the only functioning kidney, allowing surgical intervention in conditions of prolonged ischemia.

Disclosure of the Invention

The technical result of the invention is to provide the possibility of long-term (up to 180 minutes) disconnection of the kidney from the main blood flow during robotic interventions on it while reducing intraoperative and postoperative risks. The method is characterized by greater precision and subsequent suturing of the resection area with a significant reduction in trauma and the amount of blood loss. In the postoperative period, it is possible to quickly activate the patient on the 1st day after surgery, earlier removal of the safety drainage and urethral catheter. The patient can be discharged 4-5 days after surgery.

The technical result is achieved by a method of organ-preserving robot-assisted intracorporeal resection of kidney tumors, including the installation of ports for carrying out robotic manipulators, transperitoneal access to the kidney by opening the retroperitoneal space along the Toldi line, mobilization of the kidney, determination (detection) of a kidney tumor, isolation of the kidney along the renal vein, renal artery and ureter, rotation of the kidney, installation of vascular clamps like a “bulldog” on the branches of the renal artery and vein, followed by resection of the kidney tumor, removal of the clamps, followed by drainage of the retroperitoneal space and restoration of the integrity of the retroperitoneal space. Distinctive features of the claimed method are the following: before resection of the tumor, pharmaco-cold ischemia of the kidney is carried out, for which, simultaneously with the installation of ports for carrying out robotic manipulators, an additional port for carrying out an endoscopic injector is installed, pharmaco-cold ischemia of the kidney is carried out using the cardioplegic solution "Custodiol", in this case, a venotonic hole with a diameter of, for example, 1-2 mm is formed in the wall of the renal vein distal to the point of clamping, the blood is aspirated, the renal artery is punctured with an endoscopic injector distal to the clamping site, perfusion is carried out with the cardioplegic solution “Custodiol”; After removing the tumor formation within healthy tissue and removing the vascular clamp from the renal artery and hyperemia of the kidney, the residual volume of the cardioplegic solution is aspirated from the blood through the renal vein, after which the hole in the renal vein is sutured, and the vascular clamp is removed from the renal vein.

In the claimed method, anti-ischemic protection of the kidney is provided by perfusion of a cardioplegic solution through an endoscopic injector installed using robotic technology. The endoscopic injector provides injection of the Custodiol solution into the renal artery through a puncture with a diameter of less than 1 mm. This significantly reduces the traumatic nature of this manipulation, the amount of blood loss and increases the time of work on the kidney, which is disconnected from the main vessels, since it allows, in contrast to known methods, to carry out the administration of “Custodiol” completely intracorporeally (i.e. robot-assisted, without conversion) into the renal artery and partial nephrectomy. An endoscopic injector for administering the cardioplegic solution “Custoliol” is passed through an additional assistant port installed in the projection of the vascular pedicle in the closest place to reach the vessels, usually 4-5 cm above the navel along the white line of the abdomen. However, taking into account the anatomical features of the patient, this point can be shifted by 1-2 cm for safe installation of the port and insertion of the injector. This port is installed with the ability to perform puncture with minimal invasion into the arteries, which provides the subsequent possibility of precision restoration of damaged structures of the vascular and collecting systems of the kidney.

Brief description of drawings

The invention is illustrated by illustrative material: figure 1 shows a diagram of clamping of the vessels of the renal pedicle with subsequent puncture of the renal vein with an endoscopic injector; Figure 2 schematically shows a stage of the claimed method, including suturing the venotonic opening, evacuation of the cardioplegic solution “Custodiol”; Figure 3 shows a diagram of the installation of robotic ports, assistant ports and a port for administering the cardioplegic solution “Custodiol”. The positions on the figures indicate: 1 - renal artery, 2 - renal vein, 3 - kidney, 4 - kidney tumor, 5 - robotic manipulator "prograsp fenestrated", 6 - robotic manipulator "monopolar scissors", 7 - vascular clamp "bulldog" type , 8 - endoscopic injector for administering the cardioplegic solution "Custodiol", 9 - venotonic hole, 10 - puncture of the renal artery, 11 - hemostatic continuous suture, 12 - suture for the venotonic hole, 13 - robotic manipulator "needle holder", 14 - residual volume of cardioplegic "Custodiol" solution with blood from the venotonic opening, 15 - inferior vena cava, 16 - aorta, 17 - ureter, 18 - additional port intended for carrying out an endoscopic injector, 19 - port for installing a robotic manipulator "prograsp fenestrated" and/or robotic bipolar manipulator, 20 - port for installing a robotic manipulator "monopolar scissors" and/or a robotic manipulator "needle holder", 21 - port for a robotic camera manipulator, 22 - assistant port 12 mm.

Carrying out the invention

The method is carried out as follows.

With the patient in the lateral position, after treating the skin three times, 3 robotic ports are installed (Fig. 3). Using a Veress needle, gas is insufflated into the abdominal cavity. First, install the first port (21) for the robotic manipulator of the 12 mm camera, then, stepping back from it to the distance of an open palm (approximately 8-10 cm), install the second one medially towards the xiphoid process port (19) with a diameter of 8 mm for subsequent installation of a robotic bipolar manipulator and a robotic manipulator “prograsp fenestrated”. A biopolar instrument is used to coagulate tissue by generating a current between two points of contact of the instrument elements with the tissue. The robotic manipulator “prograsp fenestrated” is designed to capture and hold organs and tissues, and in the claimed method also serves for puncture of the renal artery with an endoscopic injector. The third port (20) with a diameter of 8 mm is installed, also at a distance of an open palm (approximately 8-10 cm) from the first port, laterally, 1 cm above the iliac crest, this port serves for the robotic manipulator “monopolar scissors” and “needle holder” " The robotic manipulator “monopolar scissors” is designed for cutting and coagulating tissue at the point of contact, equipped with one active electrode through which current flows from the working tool to the second neutral (passive) electrode; it is a special plate that is attached to the patient’s body. A robotic manipulator “needle holder” is used to pass surgical suture material through tissue when suturing. Also install the first assistant (fourth in total) port (22) with a diameter of 12 mm to allow aspiration of the contents of the abdominal cavity, supply of suture material and rotation of the kidney. The abdominal cavity is inspected. When performing surgery on the right kidney for liver retraction, another assistant port with a diameter of 5 mm (the fifth in total) is additionally installed to apply an Allis clamp. The retroperitoneal space is opened along Toldi's line. An area for safe isolation of the vascular pedicle is determined. The gonadal and renal veins serve as landmarks. The gonadal vein is mobilized to the level of its entry into the inferior vena cava (IVC) (for the right kidney) or the renal vein (for the left kidney), then the entry of the renal vein into the IVC is visualized. After visualization of the renal vein, dissection of the renal vein and artery is performed. In this way, a safe area is formed for clamping the vessels of the renal pedicle, after which the kidney is mobilized and the localization of the tumor is determined. The renal vein, renal artery and ureters are distinguished throughout. The kidney is rotated, and “bulldog” vascular clamps are applied to the branches of the renal artery and vein. To carry out perfusion with a cooled cardioplegic solution (“Custodiol”), a venotonic opening is acutely formed in the wall of the renal vein distal to the clamping site clamp. The blood is aspirated, after which an additional assistant port (18) with a diameter of 5 mm is installed (the sixth port for surgery on the right kidney and the fifth port for surgery on the left kidney), through which the renal artery is punctured using an endoscopic injector. This port is installed 4-5 cm above the navel along the white line of the abdomen in the projection of the intended puncture of the renal artery. The injector is passed through an additional assistant port (18) with a diameter of 5 mm; after entering the wound surface, the injector appears in the surgical field. The operating surgeon, using the prograsp fenestrated robotic manipulator, passed through the second robotic port (19), grabs the injector and directs it to the renal artery. Distal to the site of clamping of the renal artery with a bulldog clamp, the renal artery is punctured and perfused with a cooled cardioplegic solution (Custodiol). In the claimed method, it is preferable to use an endoscopic injector with a needle length of 6 mm (the maximum length of needle extension is usually 4 mm), a catheter diameter of 1.8 mm or 2.3 mm, a needle size of 25 G, a catheter length of 200 cm. Needle Intended for single use and must be disposed of after use. Products are supplied in sterile sealed packaging. The regimen for anti-ischemic protection with the cardioplegic solution “Custodiol” includes:

• solution temperature within 5-8°C;

• perfusion rate of 1 ml per 1 g of estimated kidney weight (on average 150 g in an adult);

• perfusion pressure, measured at the site of insertion of the endoscopic injector into the lumen of the renal artery, 100-110 mm Hg. (the container with the solution was placed at a height of 120-140 cm above the level of the kidney);

• perfusion time of at least 6-8 minutes (to achieve the required concentration and temperature equilibrium in the extracellular space, including intermediate tissue and the renal tubular system).

If the perfusion regimen with a cooled cardioplegic solution (Custodiol) is followed, pronounced pallor of the kidney is observed. The perfusion system is removed. Having retreated 2 mm from the tumor boundaries using monopolar coagulation, the intended resection field is marked using cauterization, then the tumor formation is sharply removed within healthy tissue. Resection of the kidney tumor is performed. The gaping vessels of the resection bottom are sutured with Z-shaped sutures using V-loс 3/0 thread. The final hemostatic continuous sutures V-loc 2/0 are applied in 2 rows, additionally secured with Hem-o-lock clips. The vascular clamp is removed from the renal artery, and renal blood flow is started. Then the residual volume of the cardioplegic solution “Custodiol” is aspirated from the renal vein. The venous opening is sutured with a continuous 5/0 Prolene suture. The vascular clamp is removed from the renal vein. The time of pharmacological ischemia is recorded. The retroperitoneal space is drained with one silicone drain. Restore the integrity of the retroperitoneal space. Remove ports. The macropreparation is removed from a mini-access. The surgical field is monitored to avoid bleeding, surgical wounds are sutured layer-by-layer, followed by the application of an aseptic dressing.

The claimed method was developed and passed clinical trials in the department of surgical treatment of urological diseases of the Federal State Budgetary Institution "National Medical Research Center of Surgery named after. A.V. Vishnevsky" of the Ministry of Health of Russia when performing robot-assisted kidney resection using pharmaco-cold ischemia with a cardioplegic solution (Custodiol) for resection of large, intraparenchymal, centrally located and multiple kidney tumors.

Examples of clinical application of the method

Example 1

Patient B., 52 years old, on February 2, 2022, was admitted to the department of surgical treatment of urological diseases of the Federal State Budgetary Institution “National Medical Research Center of Surgery named after. A.V. Vishnevsky" of the Ministry of Health of Russia to perform planned surgical intervention. At the time of hospitalization she did not actively complain. According to the patient, she considers herself sick since December 2021, when a kidney ultrasound was performed during a routine medical examination and a mass in the right kidney was detected. On December 23, 2021, the patient was sent for MSCT of the chest, abdominal cavity, retroperitoneal space and pelvis with intravenous contrast. According to the results of this study, a tumor of the anterioinferior segment of the right kidney was identified, 36 mm, encapsulated, transmurally located, adjacent to the renal sinus without obvious signs of invasion. Duplication of the pyelocaliceal system of the right kidney and the right ureter along its entire length. 8x RENAL Nephrometry Score, Intermediate complexity, 11.1% Likelihood of major complication. The blood supply to the kidney is typical. No metastases were identified at the study level. Hemangioma of the right lobe of the liver. During an examination at the Federal State Budgetary Institution National Medical Research Center for Surgery named after A.V. The Vishnevsky Medical Center of Health of Russia found no other focal pathologies in the patient.

On February 09, 2022, the patient underwent surgical intervention involving robot-assisted intracorporeal resection of the right kidney using pharmacological cold ischemia cardioplegic solution (Custodiol).

With the patient in the left lateral position, after treating the skin three times with a Veress needle, gas was insufflated into the abdominal cavity. 3 robot ports installed: 2 pcs. - 8 mm, 1 pc. - 12 mm and 3 assistant ports: 1 pc. - 12 mm and 2 pcs. 5 mm each. Revision: liver, ascending colon without pathological changes. There is no effusion in the abdominal cavity. An Allis clamp was applied to retract the liver. The right retroperitoneal space was opened along Toldi's line. The right kidney was mobilized. A round tumor about 3.5 cm in diameter was identified in the anterior inferior segment of the right kidney. The renal vein and artery, as well as two ureters (their complete doubling), are highlighted throughout. The kidney is rotated. An additional 5 mm assistant port was installed for inserting an endoscopic injector. Vascular bulldog clamps are applied to the branches of the renal artery and vein. An artificial opening was formed on the renal vein distal to the clamping site. The blood was aspirated. The renal artery was punctured using an endoscopic injector distal to the clamping site, and perfusion with a cooled cardioplegic solution (Custodiol) was established. Perfusion was performed with a solution (Custodiol) in a volume of 150 ml. The perfusion system has been removed. Marked pallor of the kidney was noted. Acute resection of the kidney was performed at a distance of 2 mm from the tumor boundaries. The gaping vessels of the resection bottom are sutured with Z-shaped sutures using V-loc 3/0 thread. Final hemostatic continuous sutures V-loс 2/0 were applied in 2 rows, additionally fixed with Hem-o-lock clips. The vascular clamp from the renal artery was removed. Kidney hyperemia. Aspiration of the residual volume of solution (Custodiol) and blood through the renal vein. The hole in the renal vein is sutured with a continuous 5/0 Prolene suture. The vascular clamp was removed from the renal vein. The pharmacological ischemia time was 23 minutes.

Drainage of the retroperitoneal space with one silicone drainage. Restoring the integrity of the retroperitoneal space. The macropreparation was removed. Ports have been removed. Hemostasis. Layer-by-layer suturing of surgical wounds was performed, followed by application of an aseptic dressing. Breathing spontaneously, the patient was transferred to the intensive care unit. The duration of the operation was 170 minutes, the console time was 145 minutes, the volume of blood loss was 200 ml.

The postoperative period proceeded without complications. The patient was discharged in satisfactory condition on the 5th day.

Example 2

Patient D., 49 years old, was admitted to the Federal State Budgetary Institution National Medical Research Center for Surgery named after A.V. Vishnevsky Ministry of Health of Russia twice - on 02/03/2022 for cicatricial stricture of the esophagus and on 03/15/2022 to perform surgical treatment of a space-occupying kidney mass. According to MSCT data dated March 16, 2022, a cystic-solid tumor of the upper segment of the left kidney was detected, 2 cm, cortically located, RENAL indicator - 4. The blood supply to the kidneys is typical. Stones in the calyces of both kidneys. A calculus in the lumen of the bladder. Cardiofundal hiatal hernia. Circular thickening of the wall of the lower third of the esophagus, compaction of paraesophageal tissue. Atherosclerosis of the aorta.

On March 25, 2022, the patient underwent surgical intervention involving robot-assisted intracorporeal resection of the left kidney using pharmaco-cold ischemia with a cardioplegic solution (Custodiol).

With the patient positioned on the right side, after treating the skin three times with a Veress needle, gas was insufflated into the abdominal cavity. 3 robot ports installed: 2 pcs. - 8 mm, 1 pc. - 12 mm and 1 assistant port -12 mm. An inspection was performed: spleen, descending colon without pathological changes. There is no effusion in the abdominal cavity. The left retroperitoneal space was opened along Toldi's line. The left kidney was mobilized. A round tumor about 2 cm in diameter was detected in the upper segment of the left kidney. The renal vein and artery and ureter are identified along the length. The kidney is rotated. An additional 5 mm assistant port was installed for inserting an endoscopic injector. Vascular bulldog clamps are applied to the branches of the renal artery and vein. An artificial opening was formed on the renal vein distal to the clamping site. The blood was aspirated. The renal artery was punctured with an endoscopic injector distal to the clamping site, and perfused with a cooled cardioplegic solution (Custodiol) in a volume of 150 ml. The perfusion system was removed. Severe pallor of the kidney was noted. Acute resection of the kidney was performed at a distance of 2 mm from the tumor boundaries. The gaping vessels of the resection bottom are sutured with Z-shaped sutures using V-loc 3/0 thread. Final hemostatic continuous sutures V-loс 2/0 were applied in 2 rows, additionally fixed with Hem-o-lock clips. The vascular clamp was removed from the renal artery. Kidney hyperemia. Aspiration of the residual volume of the Kustadiol solution and blood through the renal vein. The hole in the renal vein is sutured with a continuous suture (Prolene 5/0). The vascular clamp was removed from the renal vein. The pharmacological ischemia time was 11 minutes.

The retroperitoneal space was drained with one silicone drain. The integrity of the retroperitoneal space was restored. The macropreparation was removed. Ports have been removed. Hemostasis. Layer-by-layer suturing of surgical wounds was performed, followed by application of an aseptic dressing. Breathing spontaneously, the patient was transferred to the intensive care unit. The duration of the operation was 190 minutes, the console time was 175 minutes, the volume of blood loss was 150 ml.

The postoperative period proceeded without complications. The patient was discharged in satisfactory condition on the 5th day of the postoperative period.

Thus, the claimed method made it possible to carry out anti-ischemic protection of the kidney under the conditions of a robotic approach when performing resection of tumors of various localizations.

Example 3

Patient D., 45 years old, with multiple lesions of the right kidney (3 tumors), the largest of which is 7.5 cm.

At the National Medical Research Center for Surgery named after A.V. Vishnevsky underwent surgical intervention in the scope of robot-assisted intracorporeal resection of the right kidney using pharmaco-cold ischemia with a cardioplegic solution (Custodiol).

All manipulations performed on this patient were similar to those described in the above examples, however, given the multiple kidney lesions (3 tumors) and the large size of one of them, 7.5 cm, the pharmacological ischemia time was 170 minutes.

The duration of the operation was 240 minutes, the console time was 225 minutes, the volume of blood loss was 150 ml.

The successful start of renal blood flow and effective functioning of the kidney (according to the results of tests and ultrasound in the postoperative period) showed the effectiveness and safety of our technique.

The postoperative period proceeded without complications. The patient was discharged in satisfactory condition on the 5th day of the postoperative period.

Thus, the use of the claimed method provides the possibility of long-term disconnection of the kidney from the main blood flow during robotic interventions on it while reducing intraoperative and postoperative risks.

Claims (1)

A method for organ-preserving robot-assisted intracorporeal resection of kidney tumors, including installation of ports for carrying out robotic manipulators, transperitoneal access to the kidney by opening the retroperitoneal space along the Toldi line, mobilization of the kidney, identification of the kidney tumor, isolation of the kidney along the renal vein, renal artery and ureter, rotation kidneys, installation of vascular clamps of the “bulldog” type on the branches of the renal artery and vein with subsequent resection of the kidney tumor, removal of the clamps with subsequent drainage of the retroperitoneal space and restoration of the integrity of the retroperitoneal space, characterized in that before resection of the tumor Pharmaco-cold ischemia of the kidney is carried out using the cardioplegic solution "Custodiol", for which, simultaneously with the installation of ports for carrying out robotic manipulators, an additional port for carrying out an endoscopic injector is installed; for pharmaco-cold ischemia of the kidney, a venotonic hole is formed in the wall of the renal vein distal to the place of its clamping , the blood is aspirated, the renal artery is punctured with an endoscopic injector distal to the clamping site, and perfused with the cardioplegic solution “Custodiol”; After removing the tumor within healthy tissue and removing the vascular clamp from the renal artery and hyperemia of the kidney, the residual volume of the cardioplegic solution is aspirated from the blood through the renal vein, after which the hole in the renal vein is sutured, and the vascular clamp is removed from the renal vein.