Volume 63, Issue 6, Pages 1072-1081 (June 2013) Application of a Vasculature Model and Standardization of the Renal Hilar Approach in Laparoscopic Partial Nephrectomy for Precise Segmental Artery Clamping  Pengfei Shao, Lijun Tang, Pu Li, Yi Xu, Chao Qin, Qiang Cao, Xiaobing Ju, Xiaoxin Meng, Qiang Lv, Jie Li, Wei Zhang, Changjun Yin  European Urology  Volume 63, Issue 6, Pages 1072-1081 (June 2013) DOI: 10.1016/j.eururo.2012.10.017 Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 1 Establishment of a three-dimensional dynamic renal vasculature model. (a) Dynamic multiangle overviews of renal vasculature: (left) overview of renal vasculature from the posterior side; (middle) overview of renal vasculature from the anterior side; (right) overview of renal vasculature from the lateral side. (b) The tumor-feeding artery (target artery) in the vasculature model and its traveling course from the main renal artery to the interlobar artery; intraparenchymal arterial segments are manifested on semitransparentized parenchyma. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 2 Determination of the clamping position on the target artery. Two segmental arteries feed the tumor, and they should be clamped close to the hilar parenchyma where they have no further bifurcation before entering the parenchyma. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 3 Different hilar approaches to target arteries on the renal cross-section: (left) posterior hilar approach, (middle) anterior hilar approach, and (right) combined hilar approach. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 4 Choosing the appropriate hilar approach based on the vasculature model. (a) The renal sinus and renal artery tree. The renal sinus has an ellipsoid boundary, and segmental arteries are distributed around the boundary when they enter the sinus. Arteries entering the anterior hemiboundary (A) belong to the anterior group, and arteries the entering the posterior hemiboundary (P) belong to the posterior group. (b) Two groups of segmental arteries are shown in the vasculature model. Segmental arteries of the anterior group are marked in red and are distributed in the red circle. They should be dissected using the anterior hilar approach. Arteries of the posterior group are marked in blue and are distributed in the blue circle. They should be dissected using the posterior hilar approach. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 5 Placement of four laparoscopic ports. Port distribution varies slightly according to different surgical approaches. (Left) Port distribution for the posterior hilar approach: Port A is 2cm above the iliac crest at the midaxillary line; port D is below the 12th rib at the postaxillary line; the distance between ports B and C and between ports A and B is approximately 7cm. (Right) Port distribution for the anterior hilar approach: The four ports are placed 3cm forward to the midline compared with the posterior hilar approach. The distances between ports are unchanged. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 6 Target segmental artery dissection. (a) The dissection procedure (from A to D): (A) exposing hilar tissue; (B) excising the periarterial tissue and incising the vessel sheath; (C) orienting the spatial position of the target by exposing adjacent arteries or vein; (D) clamping the target artery. (b) The same procedure as in Fig. 6a (from A to D). The target artery is dissected using the posterior hilar approach. (c) The same procedure as in Fig. 6a (from A to D). The target artery is dissected using the anterior hilar approach. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions

Fig. 7 Venous structures can serve as important references for orientation. (Left) Intraoperative dissection of venous branches to expose the target artery between them; (right) the target artery and adjacent veins in the three-dimensional model. European Urology 2013 63, 1072-1081DOI: (10.1016/j.eururo.2012.10.017) Copyright © 2012 European Association of Urology Terms and Conditions