Medical Professional Publications

Selective Arterial Mapping May Increase Safety of Pediatric Kidney Surgery

Columbus, OH — March 2017

A technology used to remove tumors in adult kidney cancer patients appears to provide guidance and assurance to surgeons removing the poorly functioning portion of duplex kidneys in children.

Selective arterial mapping with indocyanine green dye during pediatric robot-assisted laparoscopic heminephrectomy gave surgeons real-time alerts to unexpected anatomy, physician-researchers at Nationwide Children's Hospital found.

"We think it allowed us to more safely do the surgery without risking the good part of the kidney," says Daryl McLeod, MD, a member of the Section of Urology and principal investigator in the Center for Innovation in Pediatric Practice at The Research Institute at Nationwide Children's.

In a proof-of-concept study of six patients, mapping guided surgeons to a dissection different from their anticipated route in three cases.

In one case, the flow of dye showed that an artery the surgical team believed supplied blood to the portion slated for removal was in fact perfusing the healthy portion. Without selective mapping, the vessel would likely have been cut, leading to partial or complete loss of the healthy portion of kidney, the researchers say.

"The major risk of doing this surgery is that when you take the blood supply to the part of the kidney that you're trying to remove, you may take too much of the blood supply and injure some of the good kidney," says Dr. McLeod, who is also an assistant professor of Urology at The Ohio State University College of Medicine. "Any renal function that you lose can potentially lead to complications with your entire kidney function later in life. You want to preserve as much kidney function as you can."

To try to improve safety and outcomes, the researchers tapped into a special visualization function that comes with a robotic system commonly used in urology departments.

The function allows users to see green dye and has been used in adult patients to differentiate between tumor and healthy kidney tissue. Dr. McLeod and colleagues thought dye-aided mapping could be applied to children with duplex kidneys. The poorly-functioning portion is often removed because it can cause high blood pressure.

To map which blood vessels supply only the portion of kidney to be removed, one vessel at a time is gently clamped, dye injected, and, within 30 to 60 seconds, the surgeon can see if the dye flows to the healthy or unhealthy portion of kidney. Those that flow just to the unhealthy side are cut.

Among all six cases in the study, none suffered from toxicity or vascular complications, the researchers report in a recent issue of the Journal of Pediatric Urology. The mapping added no time to surgery, when compared to others in the literature, and did not change the complexity of the operation. The only added cost was $365 for the vial of dye used in each case.

McLeod says a prospective study of this surgery with mapping is in the planning stages.

Because of the benefits indicated by this study, and the fact that most tertiary care pediatric centers use the same robotic equipment, "I think in the future, this will become commonplace," he says.

Reference:
Herz D, DaJusta D, Ching C, McLeod D. Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: a descriptive series.Journal of Pediatric Urology. 2016 Aug 12(4):266.e1-6.

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