Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: A descriptive series

Abstract

Introduction: The incidence of innocent moiety injury during heminephrectomy is estimated to be 4-5%. This complication can have long-term consequences for the child. Selective arterial mapping (SAM) with indocyanine green (ICG)-aided near infrared fluorescence (NIRF) imaging using the Firefly™ system on the da Vinci(®) surgical robotic console has proven to be valuable in robotic partial nephrectomy for adult renal tumors. However, there is nothing in the literature for using this technique in pediatric robot-assisted laparoscopic heminephrectomy (RALHN).

Objective: To present a descriptive series of children who had SAM RALHN using ICG-aided NIRF imaging. To determine the feasibility of using ICG-aided NIRF SAM during RALHN, and to study if real-time delineation of the selective arterial anatomy of the upper and lower moieties would be helpful or change the immediate outcomes of the surgery.

Study design: A descriptive series of six children who received RALHN at the present institution.

Results: Selective arterial mapping was performed safely without toxicity or vascular complications; it did not extend the operative time and did not change the complexity of the operation. As shown in the summary table below, SAM added value by increasing safety of the operation. The individual operation cost increase of using SAM was only related to the single-use vial of ICG.

Discussion: Inadvertent injury to the innocent moiety in pediatric heminephrectomy is seldom noted intraoperatively, and many times only becomes evident postoperatively when there is acute ischemia or a chronic reduction in renal function. Although there is no replacement for good surgical technique and judgment, SAM during RALHN is a useful real-time way of alerting the surgeon to unexpected anatomy, and possible unintended or occult injury to the innocent moiety that could have devastating short-term and long-term consequences to the child, despite immediate recovery from surgery.

Conclusions: This report achieved its aim of reporting the feasibility of SAM on a small descriptive series of children who had RALHN.

Keywords: Heminephrectomy; Indocyanine green; Near infrared fluorescence imaging; Robot-assisted laparoscopic; Selective arterial mapping.