Complications of laparoscopic surgery for renal masses: prevention, management, and comparison with the open experience

Comparison of the efficacy of robotic-assisted retroperitoneal laparoscopy and traditional retroperitoneal laparoscopy in partial nephrectomy among patients with renal tumors: A retrospective cohort study

PURPOSE

The efficacy of robotic-assisted retroperitoneal laparoscopy (RARL) and traditional retroperitoneal laparoscopy (TRL) in patients undergoing partial nephrectomy for treatment of a renal tumor were compared in this study.

MATERIALS AND METHODS

The retrospective study reviewed patients with renal tumors who underwent partial nephrectomy in our hospital between January 2020 and February 2022. According to different surgical methods, the patients were enrolled into the RARL (experimental group, n=65) or the TRL (control group, n=63) partial nephrectomy group.

RESULTS

One hundred twenty-eight patients were reviewed. The number of patients with collecting system injuries in the experimental group (19 cases) was significantly less than in the control group (32 cases; p<0.05). The operative time (115.7±48.2 min vs. 143.1±25.5 min) and heat ischemia time (18.7±4.9 min vs. 26.4±5.2 min) were significantly shorter in the experimental group than in the control group. The intraoperative blood loss (35.4±13.2 mL vs. 96.1±34.3 mL) and postoperative drainage volume (55.9±26.4 mL vs. 75.2±32.6 mL) were significantly less in the experimental group than in the control group (p<0.05). The change in postoperative glomerular filtration rate decrease in the experimental group was significantly lower than that in the control group (p<0.05). The change level in postoperative creatinine increase in the experimental group were significantly lower than those in the control group (p<0.05). There were no considerable differences in other clinical indicators or follow-up results between the two groups.

CONCLUSIONS

RARL was superior to TRL for renal tumor treatment with respect to operative time, intraoperative blood loss, warm ischemia time, and postoperative renal function recovery.

Efficacy and safety of cryoablation for localized renal tumor as an alternative approach to partial nephrectomy

Introduction

Renal cryoablation displays a profile of high tolerance, including in a frail population. Cryoablation appears as a validated alternative treatment to surgery for renal tumors smaller than 4 cm. However, evidence is lacking for larger tumors, despite encouraging data for tumors up to 7 cm.

Material and methods

This retrospective descriptive study of a population with a stage T1b renal tumor treated by cryoablation was conducted at the Nantes University Hospital between January 2009 and July 2021. Primary endpoint was 3-year rate of local recurrence. Secondary endpoints included technical efficacy, overall and cancer-specific survivals, and safety assessment.

Results

A total of 63 patients were analyzed. Three-year rate of local recurrence was 11.1%. Primary and secondary technical efficacies were achieved in 88.9% and 96.8% of patients, respectively, and 3-year overall and cancer-specific survival were 87.3% and 95.2%, respectively. Most patients (73%) experienced no complications, 13% of patients had minor (CIRSE grades 1 or 2) adverse effects, and 13% had severe but non-lethal (CIRSE grade 3) adverse effects. One patient died following cryoablation due to colic perforation. The most common AE (all grades) was hemorrhage (9.5%).

Discussion

This study showed a good efficacy and safety of cryoablation for renal tumors up to 7 cm (T1b). Our results were consistent with a rather sparse literature and contributed to guide future recommendations about cryoablation as an alternative to surgery for T1b renal tumors.

Laparoscopic Radical Nephrectomy in the Current Era: Technical Difficulties, Troubleshoots, a Guide to the Apprentice, and the Current Learning Curve

Abhishek Pandey, MSObjectives  The main aim of this study is to present our experience with laparoscopic radical nephrectomy (LRN) and share practical solutions to various surgical challenges and the learning curve we realized. Materials and Methods  We retrospectively analyzed our LRN database for relevant demographic, clinical, imaging, operative, and postoperative data, including operative videos. We described various complications, vascular anomalies, intraoperative difficulties, and our improvisations to improve safety and outcomes. Statistical Analysis  We evaluated the learning curve, comparing the initial half cases (group 1) against the latter half (group 2), using the chi-squared test for categorical variables and Student's t -test for continuous variables. Results  Of the 106 patients included, LRN was successful in 95% ( n  = 101), and five cases converted to open surgical approach. The mean tumor size was 7.4 cm, 42% incidentally detected. The cumulative complication rate was 15%, including five main renal vein injuries. Intraoperative difficulties included ureter identification ( n  = 6), venous bleed during hilar dissection ( n  = 11), double renal arteries ( n  = 23), and venous anomalies ( n  = 20). Arterial anatomy had 95% concordance with the imaging findings. We describe various trade tricks to perform hilar dissection, identify and control anomalous vasculature, handle venous bleed, confirm arterial control, and improve decisions using imaging, technology, and guidance of a mentor. No statistically significant difference in the learning curve was observed between the study groups. Conclusion  With LRN already established as the current standard of care, our description intends to share the trade tricks and inspire novice urologists, who can assimilate training and reproduce good results under proper guidance. The steep learning curve described in the past may not be apparent in the current era of training and technological advancement.

Initial experiences with preoperative three-dimensional image reconstruction technology in laparoscopic pyeloplasty for ureteropelvic junction obstruction

Background

To explore the clinical value of three-dimensional image reconstruction technology (3DIT) on preoperative surgical planning and perioperative outcomes in laparoscopic pyeloplasty (LP).

Methods

Data of 25 patients with ureteropelvic junction obstruction (UPJO) admitted to our hospital from January 2018 to January 2019 was analyzed retrospectively. All patients underwent preoperative enhanced computed tomography (CT) scanning. In the 12 cases in the 3DIT group, preoperative planning involved the use of virtual operation and morphometry based on reconstruction of the CT data into three-dimensional (3D) images. Surgery in the other 13 cases was performed with traditional CT examination. Demographic, surgical outcome, and postoperative parameters were compared between these two groups.

Results

Reconstructed 3D images clearly showed the spatial structural relationships between the UPJO and surrounding blood vessels. In all 25 cases surgery was completed with no conversion to open surgery. Preoperative 3DIT analyses resulted in significant improvements to mean operation time (107.76 vs. 141.58 min, P=0.024), mean time of dissociating ureteropelvic junction (UPJ) (11.26 vs. 19.40 min, P=0.020), and mean estimated blood loss volume (23.84 vs. 49.16 mL, P=0.028). There were no statistically significant differences in perioperative complications, postoperative hospital stays or postoperative drainage time.

Conclusions

3DIT based on enhanced CT scans is of clinical value in the treatment of UPJO, as it can provide accurate anatomical information and reliable guidance for preoperative operation planning, and it facilitates image-guided LP.

Laparoscopic Radical Nephrectomy

In addition to its established advantages, laparoscopic radical nephrectomy (RN) poses a unique set of challenges over traditional open surgery. In this study, we discuss preoperative considerations and detailed steps for laparoscopic RN. We review the transabdominal approach in detail, including patient positioning, equipment, and port placement in addition to the surgical steps. Intraoperative decisions such as adrenal management, renal preservation, and tumor identification are reviewed. Common complications of laparoscopic renal surgery are also summarized.

Hidden blood loss and the influencing factors after laparoscopic cholecystectomy

BACKGROUND

A small amount of bleeding usually occurs during laparoscopic cholecystectomy (LC), but the occurrence of perioperative hidden blood loss (HBL) is ignored. So our objective is to investigate the amount of HBL and find out the influential factors in LC.

METHODS

From January 2017 to May 2019, 139 patients scheduled for LC were enrolled in the study. The data of patients' sex, age, height, weight, body mass index (BMI), form of gallbladder bed, gallbladder status, hypertension, diabetes, liver cirrhosis, drainage volume and operation time were recorded. The patients' height, weight and preoperative and postoperative haematocrit and haemoglobin were recorded and applied to the Gross formula to determine the amount of blood loss. The data of sex, age, BMI, hypertension, diabetes, gallbladder status, liver cirrhosis and operation time were analysed by multivariate linear regression analysis. One-way analysis of variance was performed to find out the relative correlation between HBL and the type of gallbladder bed.

RESULTS

The HBL was 259.3 ± 188.5 mL. On the basis of multivariate linear regression analysis and analysis of variance, the gallbladder bed, hypertension and the operation time are influential factors of HBL in patients with LC. However, sex, age, BMI, gallbladder status, liver cirrhosis and diabetes are not significantly correlated with HBL.

CONCLUSIONS

HBL should not be overlooked during the perioperative period of LC, especially in patients with hypertension, gallbladder bed >50% gallbladder surface or operation time >60 min.

Comparison of Laparoscopy and Open Radical Nephrectomy of Renal Cell Cancer

Objective

The aim of this study was to summarize the current evidence to evaluate the effects of laparoscopic radical nephrectomy (LRN) and open radical nephrectomy (ORN) in the treatment of renal cell carcinoma.

Methods

A comprehensive literature search was performed using PubMed, Embase and Google Scholar to identify all relevant studies. 8 published studies were included in this meta-analysis. We pooled the odds ratios (OR), standardised mean difference (SMD) and conducted heterogeneity, and quality assessment.

Results

The outcome of treatment effects included surgical blood loss, surgical time, postoperative complications, and post-operative length of hospital stay. Comparing open radical nephrectomy for kidney cancer patients, the pooled SMD of surgical time was 0.47, (95% confidential index CI = [0.09, 0.85]), the pooled SMD of operative blood loss was -68.98, (95% CI = [-99.63, -38.34]), the pooled SMD of post-operative length of hospital stay was -4.32, (95% CI = [-4.62, -4.03]), and the pooled OR of postoperative complications was 0.52, (95% CI = [0.30, 0.91]).

Conclusion

LRN was found to significantly decrease patients’ blood loss. In addition, LRN offers less post-operative length of hospital stay.

Intestinal Injury by Heat Conduction from Surgical Sealing Devices

Background:

There have been no investigations of intestinal injury induced by surgical sealing devices, especially focusing heat conduction from the back of active blades during laparoscopic surgery.

Objective:

This study of damage to the small intestine by heat conduction from the back of active blades both physically and histopathologically was performed to establish safe usage of surgical sealing devices.

Materials and method:

We compared seven types of bipolar sealing device and two types of ultrasonic coagulating shear in an animal model simulating laparoscopic surgery. Time-dependent changes in heat conduction from the back of active blades were measured using a direct contact thermometer during intracorporeal activation. Histopathological damage to the small intestine by the back of active blades in laparoscopic surgical application was evaluated. The backs of active blades were activated while attached to the serosa of the small intestine. The depths of histopathological changes were measured to evaluate the thermal effects of surgical sealing devices.

Results:

Most devices generated temperatures >70°C even on the back of active blades. There were no significant differences in duration for cooling to ≤50°C among these devices. All devices induced histopathological heat damage in the submucosal layer or deeper.

Conclusions:

Regardless of type, the backs of active blades of surgical sealing devices conduct high temperatures and can induce heat damage in the small intestine. Surgical sealing devices should not be activated while attached to surrounding tissue or organs in laparoscopic surgery.

Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015

IMPORTANCE

Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.

OBJECTIVES

To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.

EXPOSURES

Robotic-assisted vs laparoscopic radical nephrectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.

RESULTS

Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).

CONCLUSIONS AND RELEVANCE

Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.

[Percutaneous renal ablation: Pre-, per-, post-interventional evaluation modalities and adapted management]

OBJECTIVES

Ablative treatment (AT) rise is foreseen, validation of steps to insure good proceedings is needed. By looking over the process of the patient, this study evaluates the requirements and choices needed in every step of the management.

METHODS

We searched MEDLINE^®, Embase^®, using (MeSH) words and we looked for all the studies. Investigators graded the strength of evidence in terms of methodology, language and relevance.

RESULTS

Explanations of AT proposal rather than partial nephrectomy or surveillance have to be discussed in a consultation shared by urologist and interventional radiologist. Per-procedure choices depend on predictable ballistic difficulties. High volume, proximity of the hilum or of a risky organ are in favor of general anesthesia, cryotherapy and computed tomography/magnetic resonance imaging (CT/MRI). Percutaneous approach should be privileged, as it seems as effective as the laparoscopic approach. Early and delayed complications have to be treated both by urologist and radiologist. Surveillance by CT/MRI insure of the lack of contrast-enhanced in the treated area. Patients and tumors criteria, in case of incomplete treatment or recurrence, are the key of the appropriate treatment: surgery, second session of AT, surveillance.

CONCLUSION

AT treatments require patient's comprehension, excellent coordination of the partnership between urologist and radiologist and relevant choices during intervention.

Virtual and Augmented Reality Systems for Renal Interventions: A Systematic Review

PURPOSE

Many virtual and augmented reality systems have been proposed to support renal interventions. This paper reviews such systems employed in the treatment of renal cell carcinoma and renal stones.

METHODS

A systematic literature search was performed. Inclusion criteria were virtual and augmented reality systems for radical or partial nephrectomy and renal stone treatment, excluding systems solely developed or evaluated for training purposes.

RESULTS

In total, 52 research papers were identified and analyzed. Most of the identified literature (87%) deals with systems for renal cell carcinoma treatment. About 44% of the systems have already been employed in clinical practice, but only 20% in studies with ten or more patients. Main challenges remaining for future research include the consideration of organ movement and deformation, human factor issues, and the conduction of large clinical studies.

CONCLUSION

Augmented and virtual reality systems have the potential to improve safety and outcomes of renal interventions. In the last ten years, many technical advances have led to more sophisticated systems, which are already applied in clinical practice. Further research is required to cope with current limitations of virtual and augmented reality assistance in clinical environments.

Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To provide recommendations for the management options for patients with small renal masses (SRMs). Methods By using a literature search and prospectively defined study selection, we sought systematic reviews, meta-analyses, randomized clinical trials, prospective comparative observational studies, and retrospective studies published from 2000 through 2015. Outcomes included recurrence-free survival, disease-specific survival, and overall survival. Results Eighty-three studies, including 20 systematic reviews and 63 primary studies, met the eligibility criteria and form the evidentiary basis for the guideline recommendations. Recommendations On the basis of tumor-specific findings and competing risks of mortality, all patients with an SRM should be considered for a biopsy when the results may alter management. Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. Partial nephrectomy (PN) for SRMs is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach. Percutaneous thermal ablation should be considered an option if complete ablation can reliably be achieved. Radical nephrectomy for SRMs should only be reserved for patients who possess a tumor of significant complexity that is not amenable to PN or for whom PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a nephrologist should be considered if chronic kidney disease (estimated glomerular filtration rate < 45 mL/min/1.73 m²) or progressive chronic kidney disease occurs after treatment, especially if associated with proteinuria.

Histomorphometric comparison of the human, swine, and ovine collecting systems

The ovine kidney has been recently determined to be a better model than the swine kidney for the study of collecting system healing after partial nephrectomy. However, there is no histological study comparing the collecting systems of these species. To compare human, swine, and ovine collecting systems using histomorphometry. The collecting systems of 10 kidneys from each species (human, swine, and ovine) were processed for histomorphometry. The thickness of the three layers (mucosal connective tissue, submucosal muscular, and adventitial connective tissue) were measured. The densities of smooth muscle fibers, elastic system fibers, and cells were also measured. Additionally, blood vessel density in the adventitial connective tissue was measured. Analysis of the collecting systems from the three species presented several differences. The adventitial connective tissue from the swine samples was thicker, with more blood vessels and smooth muscle fibers, compared with that from the human and ovine samples. Swine also had higher density of elastic fibers on the submucosal muscular layer. Ovine and human collecting systems shared several similar features, such as blood vessel and elastic fiber density in all layers and the density of cellular and muscular fibers in the submucosal muscular and adventitial connective tissue layers. The collecting system of the ovine kidney is more similar to that of the human kidney compared with that of the swine kidney. This may explain the differences between the healing mechanisms in swine and those in humans and sheep after partial nephrectomy. Anat Rec, 299:967-972, 2016. © 2016 Wiley Periodicals, Inc.

Prospective evaluation of complications in laparoscopic urology at a mid-volume institution using standardized criteria: Experience of 1023 cases including learning curve in 9 years

AIM:

To evaluate the laparoscopic operations performed in our department according to the modified Clavien classification system of complications.

MATERIALS AND METHODS:

Between September, 2005 and February, 2014, a total of 1023 laparoscopic cases were performed. This period was divided into three terms (Terms 1, 2 and 3 consisting of 38, 32 and 32 months, respectively). According to the European Scoring System (ESS), easy (E), slightly difficult (SD), fairly difficult (FD), difficult (D), very difficult (VD) and extremely difficult (ED) cases were 35, 88, 170, 390, 203 and 137, respectively. The perioperative complications were evaluated based on the 3 time periods, with a specific emphasis on determining the learning curve according to the modified Clavien classification system of complications.

RESULTS:

A total of 236 (23.1%) complications were observed according to the modified Clavien classification. The minor (Clavien I-II) and major (Clavien III, IV and V) complication rates were 20.5% (n = 210) and 2.4% (n = 26), respectively. Clavien I was the most frequently encountered type of complication (n = 120, %11.7). No significant difference was observed among all 3 time periods regarding total complication rates. The D cases had the highest complication rate compared to E, SD, FD, VD and ED cases among all three terms. The total number of complications increased significantly with increasing grade of technical difficulty according to the ESS.

CONCLUSION:

Complications encountered in our laparoscopic surgery experience were predominantly minor, and the rate of complications was not significantly increased during the learning curve. The present data can provide guidance and manage expectations for surgeons introducing laparoscopy into their practice.

Lateroconal fascia suspension for management of peritoneal tear and "curtain" effect during retroperitoneal laparoscopic operations

PURPOSE

To describe the method of lateroconal fascia suspension for the management of peritoneal tear and curtain effect during retroperitoneal laparoscopic operations.

MATERIALS AND METHODS

Between May 2013 and October 2014, we performed lateroconal fascia suspension in 30 cases of retroperitoneal laparoscopic operations. Peritoneal tear occurred and retroperitoneal space collapsed in 18 cases of them during the operation, and free edge of the lateroconal fascia caused curtain effect and sheltered the field of view in another 12 cases after the lateroconal fascia was incised longitudinally.

RESULTS

The curtain effect of lateroconal fascia was eliminated successfully, and the sheltered field of view got normal in all the 12 cases. The collapsed retroperitoneal space due to peritoneal tear got enlarged effectively and was sufficient for the following operations in 15 patients of the overall 18 cases, while the collapsed retroperitoneal space did not get enlarged significantly in the other three cases. After the insertion of an extra 5-mm trocar into peritoneal space, the collapsed retroperitoneal space got enlarged eventually. Finally, retroperitoneal laparoscopic operations were continued and completed successfully in all these 30 patients. It took 4 min to complete the suspension procedure, and no related complications occurred during the whole suspension process.

CONCLUSION

Lateroconal fascia suspension method could manage most peritoneal tears and curtain effect effectively during retroperitoneal laparoscopic operations.

The sheep as a model for healing studies after partial nephrectomy

BACKGROUND

The pig has been considered the best model for renal surgery. However, recent research has demonstrated that the kidney of pigs heals differently from that of humans. The objective of this study was to evaluate sheep as an alternative animal model for studying collecting system healing after laparoscopic partial nephrectomy.

MATERIALS AND METHODS

The caudal pole of the left kidney was removed from eight female adult domestic sheep using laparoscopic partial nephrectomy. Monopolar energy was used for hemostasis only in the parenchyma, avoiding coagulation near the collecting system, which was left opened. After 14 d, all animals were euthanized, and their left kidney was removed. Serum levels of urea and creatinine were assessed preoperatively and postoperatively (on days 2, 6, 10, and 14), and peritoneal fluid samples were collected during necropsy for urea and creatinine evaluation. An ex vivo retrograde pyelogram was performed, and a retrograde injection of methylene blue ink was administered to evaluate urinary leakage. Samples from the operated pole were analyzed using histologic methods.

RESULTS

During necropsy, an urinoma surrounding the operated kidney was observed in one animal. Peritoneal fluid levels of urea and creatinine were elevated. Retrograde pyelograms exhibited contrast-medium extravasation through the operated pole in all kidneys. The opened collecting system was also confirmed by methylene blue ink injection. The operated pole was covered by collagenous tissue and adhered to adjacent organs.

CONCLUSIONS

Sheep should be considered as an adequate experimental model for research on collecting system healing after partial nephrectomy.

Intraoperative laparoscopic complications for urological cancer procedures

AIM: To structure the rate of intraoperative complications that requires an intraoperative or perioperative resolution.

METHODS: We perform a literature review of Medline database. The research was focused on intraoperative laparoscopic procedures inside the field of urological oncology. General rate of perioperative complications in laparoscopic urologic surgery is described to be around 12.4%. Most of the manuscripts published do not make differences between pure intraoperative, intraoperative with postoperative consequences and postoperative complications.

RESULTS: We expose a narrative statement of complications, possible solutions and possible preventions for most frequent retroperitoneal and pelvic laparoscopic surgery. We expose the results with the following order: retroperitoneal laparoscopic surgery (radical nephrectomy, partial nephrectomy, nephroureterectomy and adrenalectomy) and pelvic laparoscopic surgery (radical prostatectomy and radical cystectomy).

CONCLUSION: Intraoperative complications vary from different series. More scheduled reports should be done in order to better understand the real rates of complications.

Comparison between laparoscopic partial nephrectomy and laparoscopic ablation therapy: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the literature evaluating comparisons on the peri-operative and oncological outcomes between laparoscopic partial nephrectomy (LPN) and laparoscopic ablation therapy (LAT) in the treatment of small renal masses (SRMs).

MATERIAL AND METHODS

MEDLINE, EMBASE, Google Scholar, Cochrane Library, and CNKI were searched for clinical trials comparing LPN with LAT. Data of peri-operative and follow-up outcomes were extracted and compared. Publication bias was identified and sensitivity analysis was also performed.

RESULTS

Data from 11 studies including 928 patients (525 patients in the LPN group and 403 in the LAT group) were collected. Baseline characteristics were compared and differences were found in age, preoperative renal function and proportion of solitary kidney (p < 0.05 respectively). For peri-operative outcomes, the LPN group had greater estimated blood loss, longer operative duration and length of hospital stay, and more peri-operative complications (p < 0.05, respectively). The LAT group had a significantly higher local recurrence (p < 0.05). There was no significant difference in postoperative change of renal function (p = 0.21).

CONCLUSION

In comparison with LPN, LAT provides better peri-operative outcomes, but a higher local recurrence rate. LAT does not seem to provide an obvious advantage in protecting renal function. Further clinical trials with randomized design and long-term follow-up are needed.

Prediction of open urinary tract in laparoscopic partial nephrectomy by virtual resection plane visualization

Background

The purpose of this study is presenting a method to predict the presence of an open urinary tract and the position of the opening in laparoscopic partial nephrectomy from three dimensional (3D) computed tomography (CT) images by using novel image segmentation and visualization techniques.

Methods

From CT images of patients who underwent laparoscopic partial nephrectomy, 3D regions of the kidney, urinary tract, and tumor were segmented. For each patient, multiple virtual resection planes of the kidney with different surgical margins (1 mm to 5 mm, every 1 mm) were generated and the presence of an open urinary tract and the position of the opening were predicted from the images.

Results

We compared the predictions with actual operations in 5 cases by using recorded video of the operations and operative notes. In terms of the presence of an open urinary tract, agreement of the predictions and the intraoperative results was obtained in all patients. The expected positions of the openings were close to those in the actual operations.

Conclusions

We have developed a method to virtually visualize the resection plane of laparoscopic partial nephrectomy. Image segmentation methods used in this study were precise and effective. The comparison indicated that our method accurately predicted the presence of an open urinary tract and the position of the opening and provided useful preoperative information.

[Open and minimally invasive partial nephrectomy. Management of complications]

Current guidelines increasingly recommend organ-preserving surgical procedures in the treatment of renal tumors. Both the open surgical and minimally invasive surgical techniques are well established. In the literature, various systems for the systematic evaluation of comorbidities and complications have been reported. Already while taking the patient's history and preoperative planning prior to partial nephrectomy, it is recommended that a detailed risk assessment be carried out regarding expected complications. Essentially the two critical factors - the comorbidities of the patient and anatomic complexity level of the tumor - should be evaluated in order to achieve the best possible selection of patients for a partial nephrectomy and the determination of the surgical method.

Laparoscopic radical and partial nephrectomy: The clinical efficacy and acceptance of the techniques

The laparoscopic approach has been established as the surgical procedure of choice for radical nephrectomy during the recent years. The advantages of the laparoscopic radical nephrectomy in comparison to the open approach are well-documented. The oncological results of the laparoscopic approach are similar to the open procedure while the post-operative morbidity is lower. Laparoscopic partial nephrectomy seems to gain ground to its open counterpart, as the accumulation of experience in the technique grows. In this review, a PubMed search in the latest literature on radical and partial laparoscopic nephrectomy took place and the outcome of the search is presented. Several issues about the surgical techniques and clinical efficacy are discussed. In addition, the preliminary experience in laparoscopic nephrectomy of one of the authoring institutions is also presented.

[Nephrectomy: complication management]

BACKGROUND

Nephrectomy is a standard procedure that is associated with a low complication rate.

OBJECTIVES

Based on an analysis of the literature, expert recommendations, and our own experience, the management of complications during and after nephrectomy is described.

RESULTS

Complications during and after nephrectomy can be avoided by careful surgical planning, optimal approach and exposure, and precise knowledge of the principles of anatomy. The treatment of bleeding complications and injuries to neighboring structures are essential elements in the management of complications. Hernia and relaxation of the lumbar muscles should be avoided.

CONCLUSION

Morbidity associated with nephrectomy can be reduced by careful surgical planning and paying attention to the basic anatomical and surgical principles.

Multiple renal arteries with renal cell carcinoma: Preoperative evaluation using computed tomography angiography prior to laparoscopic nephrectomy

Objective

To investigate anatomical variations in the renal arteries of patients with renal cell carcinoma (RCC) using computed tomography angiography (CTA).

Methods

Patients diagnosed with RCC were evaluated using CTA prior to undergoing laparoscopic nephrectomy. Any anatomical variations of the renal arteries on the side affected by the RCC were recorded. The CTA results were compared with the observations made during surgery and those produced by conventional digital subtraction angiography.

Results

A total of 107 patients with RCC were enrolled in the study. Multiple renal arteries were found in 11 patients (10.3%). Accessory renal inferior polar arteries were the most common type of multiple renal arteries. Multiple renal arteries acting as the feeding arteries to the RCC were found in five patients (4.7%).

Conclusion

CTA can be used as part of the preoperative evaluation prior to laparoscopic nephrectomy to provide anatomical information about the presence of multiple renal arteries in the affected kidney of patients with RCC. This could help with planning the surgery and reducing surgical complications.

Transperitoneal laparoscopic radical nephrectomy in a patient with severe scoliosis

OBJECTIVE

To report the first case of a left transperitoneal laparoscopic nephrectomy in a patient with a severe left convex lumbar scoliosis and to elaborate on the technical difficulties of this procedure.

METHODS

The surgical procedure was performed by an experienced laparoscopic surgeon after rigorous pre-operative visualization of the altered visceral and vascular abdominal anatomy. A transperitoneal laparoscopic approach with an open introduction technique according to Hasson and a caudo-cranial dissection of the left renal hilum were performed to prevent major vascular and visceral injury in this challenging surgical procedure.

RESULTS

The operation time was 102 minutes and the estimated blood loss was 100 mL. The surgeon was able to complete the transperitoneal laparoscopic radical nephrectomy without complications.

CONCLUSION

Transperitoneal laparoscopic radical nephrectomy in patients with severe spinal deformities is feasible, but should only be performed by experienced laparoscopic surgeons to ensure patient safety and cancer control.

Operative safety and oncologic outcome of laparoscopic radical nephrectomy for renal cell carcinoma >7 cm: a multicenter study of 222 patients

OBJECTIVE

To evaluate the safety of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) >7 cm, addressing the issue of modality and risk factors for complications and open conversion, and to assess the oncologic outcome.

METHODS

The data of 222 patients undergoing LRN for RCC >7 cm prospectively enrolled from 2002 to 2010 at 5 urologic centers were reviewed. Transperitoneal LRN was performed by 5 experienced laparoscopic surgeons. The Clavien-Dindo classification was used to assess complications. Multivariable analysis of factors predictive of conversions was performed. Oncologic outcomes for survival were estimated using the Kaplan-Meier method.

RESULTS

Median tumor size was 8.5 cm, operative time was 180 minutes, and blood loss was 280 mL. Forty-two patients (19%) received a blood transfusion. Six (2.7%) patients had grade III-IV complications: 2 with postoperative bleeding requiring abdominal re-exploration and 1 each with adrenal injury, splenic injury, wound diastasis, and respiratory insufficiency. Twelve patients (5.4%) were converted to open surgery. The diameter was 11.9 in converted groups and 8.5 cm in nonconverted groups (P = .001). Multivariable analysis revealed that pathologic stage was the only independent predictor of conversion (P = .002). The 5-year overall (OS), cancer-specific (CSS), and progression-free (PFS) survival was 74%, 78%, and 66%, respectively. The 5-year stage-adjusted CSS was 89% in pT2 and 40% in pT3 patients (P <.0001). Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome.

CONCLUSION

LRN for large RCC is a safe operation. Stage pT3 is a risk factor for open conversion and is associated to significantly lower cancer-specific survival compared with pT2 stage.

Transperitoneal laparoscopic nephrectomy for autosomal dominant polycystic kidney disease

Compared to open surgery, laparoscopic nephrectomy for autosomal dominant polycystic kidney disease appears to be a feasible and safe approach.

Objective:

This study focuses on laparoscopic nephrectomy for autosomal dominant polycystic kidney disease (ADPKD).

Material and Methods:

We retrospectively reviewed 21 consecutive patients who had previously undergone laparoscopy between 2007 and 2010. Data were compared to that obtained from 19 consecutive patients who had open surgery between 2004 and 2007. Clinical parameters, operative data, perioperative mortality, postoperative complications, and length of hospital stay were compared using χ² and Student t tests for qualitative and quantitative variables, respectively.

Results:

Nephrectomy is usually performed to create space for renal transplantation (81% and 79%, respectively). Operating time was longer with the laparoscopic approach (180 min vs. 128 min, P = .001). Blood loss was comparable in the 2 groups (154 vs. 222 ml, P = .359) but 3 patients were transfused in the open surgery group as compared with 1 patient in the laparoscopic group. No conversion was needed. There was a trend in the laparoscopic group with respect to lower consumption of analgesics in the postoperative period (P = .06). Delay to transit recovery (2.1 d vs 4.1 d, P < .001) and hospital stay (5.2 d vs. 8.28 d, P = .002) were significantly decreased in the laparoscopic group. The interval from surgery to renal transplantation was lower in patients operated on laparoscopically (3.1 vs. 12 mo). Complications occurred in 33% of the patients in the laparoscopic group as compared with 68% in the open surgery group (P = .22). Severe complications were less frequent in the laparoscopic group (9.5% vs. 37%, P = .04).

Conclusion:

Laparoscopic nephrectomy is a feasible and safe procedure for ADPKD. Morbidity is significantly reduced compared with the open approach.

[Combined approach of laparoscopic and open surgery for complex renal lesions]

OBJECTIVE

To develop a combined surgical approach (laparoscopic and open) that allows an increased vascular control and decreased ischemia time, maintaining the advantages of pure laparoscopic partial nephrectomy (LPN).

MATERIAL AND METHODS

During the laparoscopic phase, dissection of the kidney and its pedicle is achieved. Then, an open approach is initiated through a mini-laparotomy, with the kidney being brought to the incision, improving the identification and exposition of the tumors. Following tumor identification by ultrasound, exeresis of the lesion is performed with or without vascular clamping.

RESULTS

Through this approach we performed the excision of complex lesions in 6 patients. Mean surgical time was 192 minutes (range 180-210) and mean warm ischemia time was 13 minutes (0-22), with a mean blood loss of 267 mL (100-500). Average pre and postoperative glomerular filtration rate was 51.5 (28-90) and 48.8 mL/min/1.73 m(2) (19-90), respectively. In one patient, suture repair of the pelvicaliceal system was needed, with no other perioperative morbidities being reported.

CONCLUSIONS

This combined approach is a minimally invasive surgical alternative, reproducible and safe which preserves the virtues of pure LPN. It allows a better control of the vascular pedicle, reducing the risk of hemorrhage and the warm ischemia time. This technique may be either considered in the treatment of renal masses with indication for partial nephrectomy but of complex laparoscopic approach or as a surgical approach in the early learning curve of the LPN.

Systemic adjuvant therapies in renal cell carcinoma

Renal cell carcinoma (RCC) is one of the ten most frequent solid tumors worldwide. Recent innovations in the treatment of metastatic disease have led to new therapeutic approaches being investigated in the adjuvant setting. Observation is the only current standard of care after radical nephrectomy, although there is evidence of efficacy of adjuvant use of vaccine among all the strategies used. This article aims to collect published experiences with systemic adjuvant approaches in RCC and to describe the results of past and ongoing phase III clinical trials in this field. We explored all the systemic treatments, including chemotherapy, immunotherapy and targeted drugs while alternative approaches have also been described. Appropriate selection of patients who would benefit from adjuvant therapies remains a crucial dilemma. Although the international guidelines do not actually recommend any adjuvant treatment after radical surgery for RCC, no conclusions have yet been drawn pending the results of the promising ongoing clinical trials with the target therapies. The significant changes that these new drugs have made on advanced disease outcome could represent the key to innovation in terms of preventing recurrence, delaying relapse and prolonging survival after radical surgery for RCC.

Partial nephrectomy: is there an advantage of the self-retaining barbed suture in the perioperative period? A matched case-control comparison

OBJECTIVE

To evaluate the efficacy of the self-retaining barbed suture (SRBS) in renal defect repair during partial nephrectomy (PN), by assessing perioperative outcomes.

METHODS

From June 2010 on we have been using the SRBS for superficial layer closure during open and laparoscopic PN in two European centers. These data were collected prospectively and matched with historical PN cases performed with conventional suture. Cases were matched for PADUA score, surgical approach (laparoscopic or open) and the center where surgery was performed. Comparisons were made in patient characteristics and perioperative outcomes including warm ischemia time (WIT), changes in hemoglobin (Hb), changes in estimated glomerular filtration rate (eGFR) and perioperative complications between the SRBS and non-SRBS groups. Statistical tests of significance were performed using Student's t test and chi-square test for continuous and categorical variables, respectively.

RESULTS

Thirty-one consecutive cases of PN under WIT were performed with SRBS. These cases were matched with cases from the historical database of PN performed with conventional suture. The rate of perioperative complications was statistically significantly lower in the SRBS cohort (6.5 vs. 22.6 %, p = 0.038). Mean ischemia time was 19.6 min (SD, 7.5) in the SRBS group versus 21.8 min (SD, 9.5) in the conventional suture group (p = 0.312). There were no significant differences between groups for postoperative changes in creatinine, eGFR and Hb. Limitations of this study include the absence of randomization and the relative small sample size.

CONCLUSIONS

SRBS can be safely used during partial nephrectomy. SRBS reduces significantly the number of perioperative complications.

An overview of image-guided percutaneous ablation of renal tumors

Although nephron-sparing surgery remains the gold standard treatment for small renal tumors, minimally invasive image-guided percutaneous ablation is becoming a viable alternative to operative resection. Percutaneous radiofrequency ablation (RFA) and cryoablation show high technical success rates, a relatively low incidence of residual or recurrent tumor, and competitive rates of patient survival. In this review, an overview of the current status of image-guided percutaneous ablation of renal tumors is presented, with a focus on procedure indications and patient selection, technical aspects of ablation procedures, and treatment outcomes and patient follow-up.

[Partial nephrectomy - pro laparoscopy]

Partial nephrectomy has become the most frequently used surgical procedure in the treatment of renal cell cancer. The current role of laparoscopy for this indication has to be defined.The technique of laparoscopic partial nephrectomy has undergone a continuous development to become mature. Once the learning curve of the individual surgeon has been overcome the results are comparable to those of open surgery. This is true for ischemia time, complication rate and oncologic outcome. In addition there is the advantage of the minimally invasive approach in laparoscopy sparing a painful flank incision. Laparoscopic partial nephrectomy is not yet a standard of care but yields excellent results in the hands of experts. There are no conclusive studies comparing standard and da Vinci®-assisted laparoscopy. No clear advantages become obvious, but the costs of the robot are substantial.