Retroperitoneal laparoscopic nephron-sparing surgery for renal tumors: Report of 32 cases

Safety, Efficacy and Mid-Term Outcome for Transarterial Embolization (TAE) of Renal Angiomyolipoma (AML) Using Ethylene Vinyl Alcohol Copolymer Liquid Embolic Agent (EVOH)

Transarterial embolization (TAE) of renal angiomyolipoma (AML) is effective in treating and preventing hemorrhage. We report our experience using EVOH with a single-center retrospective study of all AML embolized with EVOH between June 2013 and March 2022 at the Montpellier University Hospital. A total of 29 embolizations were carried out in 24 consecutive patients (mean age: 53.86 years; 21 women and 3 men) with 25 AMLs for severe bleeding, symptomatic AML, tumor size > 4 cm, or presence of aneurysm(s) > 5 mm. Data collected included imaging and clinical outcomes, tuberous sclerosis complex status, change in AML volume, rebleeding, renal function, volume and concentration of EVOH used, and complications. Out of 29 embolizations performed for 25 AMLs, four were performed in an emergency. Technical success was achieved for 24/25 AMLs. Mean AML volume reduction was 53.59% after a mean follow-up time of 446 days using MRI or CT scan. Aneurysms on angiogram and the symptomatological nature of AML, as well as secondary TAE and multiple arterial pedicles, were statistically associated (p < 0.05). Two patients (8%) underwent nephrectomy after TAE. Four patients had a second embolization. Minor and major complication rates were 12% and 8%, respectively. Neither rebleeding nor renal function impairment was noticed. TAE of AML using EVOH is, thus, highly effective and safe.

Tumor enucleation for the treatment of T1 renal tumors: A systematic review and meta-analysis

Purpose

To evaluate the clinical efficacy and safety of tumor enucleation (TE) compared with partial nephrectomy (PN) for T1 renal cell carcinoma.

Materials and Methods

According to protocol, we searched multiple data sources for published and unpublished randomized controlled trials and nonrandomized studies (NRSs) in any language. We performed systematic review and meta-analysis according to the Cochrane Handbook for Systematic Reviews of Interventions and rated the certainty of the evidence (CoE) using the GRADE framework.

Results

We are uncertain about the effects of TE on perioperative (mean difference [MD] 3.38, 95% CI 1.52 to 5.23; I²=68%; 4 NRSs; 942 participants; very low CoE) and long-term (MD 2.31, 95% CI -1.40 to 6.01; I²=57%; 4 NRSs; 542 participants; very low CoE) residual renal function. TE may result in little to no difference in short-term residual renal function (MD 1.04, 95% CI 0.25 to 1.83; I²=0%; 2 NRSs; 256 participants; low CoE). We are uncertain about the effects of TE on cancer-specific mortality (risk ratio [RR] 0.90, 95% CI: 0.11 to 7.28; I²=0%; 2 NRSs; 551 participants; very low CoE) and major adverse events (RR 0.48, 95% CI: 0.30 to 0.79; I²=0%; 10 NRS; 2,360 participants; very low CoE).

Conclusions

While TE appears to have similar effects on short term postoperative residual renal function, there were uncertainties on mortality and major adverse events. However, we need rigorous RCTs to elucidate the effects of TE as the evidence stems mostly from NRSs.

Prediction of pentafecta achievement following laparoscopic partial nephrectomy: Implications for robot-assisted surgery candidates

BACKGROUND

In clinical practice, objective basis for the choice between laparoscopic partial nephrectomy (LPN) and robot-assisted partial nephrectomy (RAPN) is scarce. To evaluate surgical outcomes, assess the individual benefit from LPN to RAPN, which can guide clinical decision-making.

METHODS

Patients underwent LPN or RAPN for a localized renal mass in our center between Jan 2013 and Dec 2016 were included. The surgical outcome of LPN and RAPN was the pentafecta achievement. A multivariable model was fitted to predict the probability of pentafecta achievement after LPN. Model-derived coefficients were applied to calculate the probability of pentafecta achievement in case of LPN among patients treated with RAPN. Locally weighted scatterplot smoothing method was applied to plot the observed probability of pentafecta achievement against the predicted pentafecta probability in case of LPN.

RESULTS

RAPN group had a significantly higher pentafecta achievement (54.6% vs. 41.1%, P < 0.001) than LPN. Multivariable analyses identified that tumor size, distance of the tumor to collecting system or sinus, and preoperative eGFR were independent predictors of pentafecta after LPN. When RAPN was chosen over LPN, the increase in the probability of pentafecta achievement was greatest in intermediate-probability patients. With the increase or decrease of the probability of pentafecta, the benefit of RAPN decreased.

CONCLUSION

When pentafecta achievement are assessed, the benefit of RAPN over LPN varies from patient to patient. Patients at intermediate-probability of pentafecta achievement after LPN benefit the most from robotic surgery, which may be the potential ideal candidates for RAPN.

Emergency retroperitoneal laparoscopic partial nephrectomy for ruptured renal angiomyolipomas: a retrospective single-center series of 15 cases

Background

To assess the safety, tumor control and renal function preservation of the emergency retroperitoneal laparoscopic partial nephrectomy (LPN) for ruptured renal angiomyolipoma (AML) and summarize our single-center initial experience.

Methods

We performed a retrospective analysis of 15 patients pathologically confirmed renal AML treated with emergency retroperitoneal LPN between January 2016 and May 2019. The patient demographics, operation time, blood loss, transfusion requirements, complications and other surgical parameters were analyzed. Follow-up was performed by serum creatinine and imaging modalities.

Results

Fifteen patients were performed with emergency LPN with the median age 41.6 years. The mean size of the renal AMLs was 7.8 cm. The mean size of the retroperitoneal hematomas was 8.5 cm. All the emergency surgeries were performed successfully without any conversion to nephrectomy or open surgery. The mean operative time was 101 min. The mean warm ischemia time was 28 min. The mean estimated blood loss was 311 ml. Five patients required intraoperative blood transfusion (33.3%, 5/15). The mean transfused RBC was 4 U (range 2-6 U), and the mean transfused plasma was 200 ml (range 200-400 ml). The mean drainage duration was 3 days (range 2–5 days). The mean postoperative hospitalization was 4.7 days. No patients experienced intraoperative complications. The mean serum creatine was slightly higher after surgery (53.1 vs. 55.9 μmol/L). One patient had postoperative perirenal fluid collection. No patients needed dialysis. No recurrence was observed in the patients at the median follow-up of 24.1 months.

Conclusions

Our initial experience shows that the emergency retroperitoneal LPN is a safe, minimally invasive procedure for emergency patients with ruptured renal AMLs. It could be considered as an effective alternative to renal artery embolization in selected emergency patients.

Retroperitoneal laparoscopic nephron sparing surgery for large renal angiomyolipoma: Our technique and experience. A case series of 41 patients

OBJECTIVES

To introduce a 'kidney priority' strategy in treating large renal angiomyolipoma (RAML) with retroperitoneal laparoscopic nephron sparing surgery (RLNSS).

PATIENTS AND METHODS

From 2010 to 2017, 41 patients with large RAML underwent RLNSS. Distinguished from the standard practice, the kidney was preferentially mobilized and separated from the RAML. Subsequently, it was reconstructed. Finally, the RAML was resected from the perinephric fat. The perioperative variables, surgical technique and complications were reviewed. Patients were followed up with ultrasonography and computed tomography.

RESULTS

RLNSS was successfully performed in 35 patients with four conversions to open surgery and two conversions to nephrectomy, respectively. Eight patients required an intraoperative blood transfusion. Seven patients experienced postoperative complications, including one wound infection, one urinary tract infection, one pneumonia, one urinary fistula and three hemorrhage. The median operation time was 167min (range, 95-285min), the median warm ischemia time was 21 min (range, 0-40 min), and the median estimated blood loss was 200 ml (range, 30-2500 ml). The median postoperative stay was 6.5 days (range, 3-11 days). Angiomyolipoma was confirmed pathologically in all patients. Median serum creatine increased after surgery, from 0.7 mg/dl (range, 0.4-1.1 mg/dl) preoperatively to 0.8 mg/dL (range, 0.5-1.4 mg/dl) postoperatively (P = 0.016). No patient required dialysis, and no recurrence was observed after a median follow-up of 35 months (range, 3-85 months).

CONCLUSIONS

RLNSS is a safe, feasible, effective and minimally invasive procedure to manage large RAML in selected patients.

Bilateral Synchronous Sporadic Renal Cell Carcinoma: Retroperitoneoscopic Strategies and Intermediate Outcomes of 60 Patients

OBJECTIVE

To evaluate the presentation, management, pathology, and functional and oncological outcomes of patients undergoing retroperitoneoscopic treatment of bilateral synchronous sporadic RCC at our institution.

METHODS

We retrospectively evaluated the records of 60 patients with bilateral synchronous sporadic RCC who underwent retroperitoneoscopic treatment at the General Hospital of People's Liberation Army from 2008 to 2014. The estimated glomerular filtration rate was calculated and compared among different surgical procedures. The overall survival and recurrence free survival were assessed based on information from recent follow-up.

RESULTS

Fifty-six patients underwent bilateral retroperitoneoscopic surgeries in staged procedures, and four patients underwent bilateral retroperitoneoscopic surgeries in simultaneous procedures. Among the former group of patients, 34 underwent bilateral partial nephrectomy, 12 underwent radical nephrectomy followed by partial nephrectomy, and 10 underwent partial nephrectomy followed by radical nephrectomy. Bilateral partial nephrectomy can better preserve renal function (p = 0.040) and the sequence of partial nephrectomy and radical nephrectomy did not affect functional outcomes (p = 0.790). One patient undergoing simultaneous procedures developed acute renal failure and required temporary hemodialysis. At 3 and 5 years, overall survival rates were 93.0% and 89.4%, and recurrence free survival rates were 90.5% and 81.6%. High nuclear grade (p = 0.014) was related to disease recurrence.

CONCLUSIONS

Staged bilateral partial nephrectomy was efficient in preserving renal function. The survival of patients with bilateral synchronous sporadic renal tumors was similar to that of patients with unilateral nonmetastatic tumors. Nuclear grade was an independent prognostic factor of disease recurrence.

Evaluation of PADUA Score as Predictor of Warm Ischemia Time (WIT) during Laparoscopic Partial Nephrectomy (LPN)

Objective

To evaluate the efficacy of Preoperative Aspects and Dimension Used for an Anatomical (PADUA) classification in the prediction of Warm Ischemia Time (WIT) during Laparoscopic Partial Nephrectomy (LPN).

Methods

Single centre retrospective study on 402 patients who underwent LPN between January 2011 and October 2013. WIT was correlated with each characteristics of the PADUA classification. Univariate and multivariate analysis were used to evaluated the independent predictive risk factors of WIT >20 minutes.

Results

The median WIT was 19.8 minutes (IQR 15-25). The PADUA risk groups (High vs Low: OR: 2.804; 95% CI 1.155-6.806; p-value <0.001; Intermediate vs Low: OR 0.971; 95% CI 0.185-5.092 p-value <0.001) and PADUA score as continuous variable (OR: 1.512; 95% CI 1.043-2.194; p-value <0.001) were the best independent risk factors of WIT >20 minutes. Another important factor related with WIT >20 minutes was a CKD stage 3 (p-value: 0.047; OR: 0.528; 95% CI:0.282-0.990).

Conclusions

This study reveal that tumor’ anatomical aspects may influence the WIT. The use of the nephrometry scoring systems should to be use by the surgeon in the planning of nephron sparing surgery (NSS) and should be considered for its inclusion in international guidelines.

Comparison of robot-assisted and laparoscopic partial nephrectomy for complex renal tumours with a RENAL nephrometry score ≥7: peri-operative and oncological outcomes

OBJECTIVE

To evaluate the peri-operative, functional and oncological outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for moderately or highly complex tumours (defined as RENAL nephrometry score ≥7).

PATIENTS AND METHODS

We retrospectively analysed the medical charts of 216 patients with complex tumours who underwent LPN (n = 135) or RAPN (n = 81) between 2008 and 2014. Peri-operative data, pathological variables, complications, functional and oncological outcomes were reviewed.

RESULTS

Demographic characteristics were similar in the two groups. LPN was associated with a longer operating time (149.6 vs 135.6 min; P = 0.017) and greater estimated blood loss (220.8 vs 196.5 mL; P = 0.013). RAPN was associated with a higher direct cost. There were no differences in warm ischaemia time, transfusion rate, conversion rate, hospital stay, operative complications and estimated glomerular filtration rate change at 6 months after surgery. The mean follow-ups for LPN and RAPN were 31.4 and 16.5 months, respectively. The 3-year recurrence-free survival rate was 95.2% for LPN and 97.1% for RAPN (P = 0.71).

CONCLUSION

In patients with complex tumours, RAPN and LPN provided acceptable and similar results in terms of peri-operative, functional and oncological outcomes. RAPN was superior to LPN in terms of estimated blood loss and operating time, and LPN was the more cost-effective approach. Both surgery techniques remain viable options in the management of complex tumours with RENAL scores ≥7.

Experience with retroperitoneal partial nephrectomy in bilateral Wilms tumor

INTRODUCTION

Retroperitoneal partial nephrectomy has not been studied as a surgical approach for children with bilateral Wilms tumor. There are advantages to this technique, including isolation of urine leaks to the retroperitoneum, decreased risk of bowel injury, and decreased time to resuming a diet. Presently, all bilateral Wilms tumors are treated with neoadjuvant chemotherapy and attempted nephron-sparing surgery. In this study, we compare the outcomes of the retroperitoneal and transabdominal approaches in doing partial nephrectomy for bilateral Wilms tumor.

METHODS

With the institutional review board approval, we reviewed records of 14 pediatric patients with metachronous or synchronous bilateral Wilms tumors who underwent surgery after chemotherapy between 1994 and 2014. Only operative procedures with the intent to cure were included (n=15) and of these, 5 procedures were retroperitoneal and 10 were transabdominal in approach. Individual kidneys operated upon (n=26) were analyzed using the preoperative radius exophytic/endophytic nearness anterior/posterior location nephrometry score to ensure that resected tumors were comparable between the two surgical groups. Charts were retrospectively analyzed for intraoperative parameters and postoperative course. Differences between parameters were evaluated using Mann-Whitney and chi-square tests.

RESULTS

Resected tumors in both surgical treatment groups had comparable sizes, nephrometry scores, and rates of anaplasia. Operative time, blood loss, and transfusion requirement were similar between the two groups. The extent of lymph node sampling and rates of R0 resection were equivalent. One adverse intraoperative event, a bowel enterotomy, was seen in the transabdominal group. Patients after retroperitoneal partial nephrectomy required half the time to return to an oral diet as compared with those after a transabdominal surgery, approaching statistical significance (p=0.08). Rates of the postoperative urine leak were similar, though two in the transabdominal group required reoperation for drainage. There were four recurrences, all in the transabdominal group.

CONCLUSION

Our experience demonstrates that the retroperitoneal approach is equivalent to the transabdominal technique with regards to intraoperative complications, lymph node dissection, and R0 resection. Advantages include less time to resumption of oral feeding, decreased risk of bowel injury, and isolation of urine leaks to the retroperitoneum. It should be considered a viable surgical option in the treatment of bilateral Wilms tumors.

Renal sparing surgery using focus ultracision harmonic scalpel in patients with bilateral wilms' tumor: case report

BACKGROUND

Bilateral Wilms' tumor is rare and surgical treatment requires an individual approach. Surgical approach to the tumors located in the central part of the kidney represents a major challenge and nephrectomy is usually essential. Renal sparing surgery is difficult in such cases.

CASE REPORT

We describe a 3 year-old female patient with bilateral Wilms' tumor arising in the central localisation of the right and foci in the left kidney enucleated successfully with a simple and comfortable renal preserving operative technique using Focus Ultracision Harmonic Scalpel.

CONCLUSION

In cases when tumors are located in the central part of the kidney and partial nephrectomy is consequently very difficult, the use of a Focus Ultracision Harmonic Scalpel provides easy dissecting, enucleation, and excision of the tumor.

Evolving renorrhaphy technique for retroperitoneal laparoscopic partial nephrectomy: single-surgeon series

OBJECTIVES

To evaluate renorrhaphy techniques and to analyze surgical outcomes in retroperitoneal laparoscopic partial nephrectomy.

METHODS

A retrospective study from January 2008 to December 2011 analyzed 526 patients with renal tumors in whom renorrhaphy was changed from one layer, interrupted, figure-of-eight (n = 228) suture to two layers, continuous, unknotted (n = 298) suture. All procedures were carried out by the same laparoscopic surgeon (XZ). Patient demographics, tumor characteristics, operative outcomes and perioperative renal function were compared.

RESULTS

Median follow up for one layer, interrupted, figure-of-eight suture and two layers, continuous, unknotted suture was 31 and 28 months, respectively. The two layers, continuous, unknotted suture group had shorter warm ischemia time (P = 0.021), faster removal of Jackson-Pratt drains (P = 0.029) and shorter hospital stay (P = 0.037) than the one layer, interrupted, figure-of-eight suture group. There was a trend towards a better preservation of glomerular filtration rates in the two layers, continuous, unknotted suture group (P = 0.045). In a multivariable model, the two layers, continuous, unknotted suture technique was a statistically significant independent predictor of warm ischemia time (P = 0.01), hospital stay (P = 0.001) and estimated glomerular filtration rates (P = 0.043).

CONCLUSIONS

Two layers, continuous, unknotted suture renorrhaphy allows better outcomes than one layer, interrupted, figure-of-eight suture renorrhaphy in retroperitoneal laparoscopic partial nephrectomy. A longer clinical follow-up evaluation is warranted.

Spontaneous Retroperitoneal Hemorrhage (Wunderlich Syndrome) due to Large Upper Pole Renal Angiomyolipoma: Does Robotic-Assisted Laparoscopic Partial Nephrectomy Have a Role in Primary Treatment?

Spontaneous rapture with consequent retroperitoneal hemorrhage (Wunderlich's syndrome) is the complication mostly feared from large renal angiomyolipomas (RAMLs). In hemodynamic stable patients, minimal invasive therapies have superseded open surgery as the mainstay of treatment, with contemporary cases mostly treated by selective arterial embolization. Robotic-assisted laparoscopic partial nephrectomy (RALPN) is an established minimal access treatment that has been used in the past for benign and malignant lesions of the kidney in the elective setting, but rarely in urgent situations as primary treatment. We present a case of a ruptured RAML in a young female treated effectively by RALPN.

Medial arcuate ligament: a new anatomic landmark facilitates the location of the renal artery in retroperitoneal laparoscopic renal surgery

PURPOSE

The purpose of this study was to introduce a new method for locating the renal artery during retroperitoneal laparoscopic renal surgery.

PATIENTS AND METHODS

The medial arcuate ligament (MAL) is a tendinous arch in the fascia under the diaphragm that arches across the psoas major muscle and is attached medially to the side of the first or the second lumbar vertebra. The renal artery arises at the level of the intervertebral disc between the L1 and L2 vertebrae. We evaluate the role of the MAL that serves as an anatomic landmark for locating the renal artery during retroperitoneal laparoscopic renal surgery.

RESULTS

There is a reproducible consistent anatomic relationship between MAL and the renal artery in 210 cases of retroperitoneal laparoscopic renal surgery. Two main types of the MAL, the "narrow arch" and the "fascial band" types, can be observed.

CONCLUSION

MAL can serve as an accurate and reproducible anatomic landmark for the identification of the renal artery during retroperitoneal laparoscopic renal surgery.

Selective arterial embolization of giant renal tuberous sclerosis

Different minimally invasive methods have been proposed to treat renal manifestation of tuberous sclerosis complex (TSC), in order to preserve kidney parenchyma and avoid nephrectomy. The case of a boy with bleeding giant angiomyolipoma treated by selective arterial embolization is discussed. The extensive renal lesions resulted significantly decreased, with resolution of arterial hypertension and abdominal symptoms. Differential renal function increased from 26.6% to 32.6%. Renal involvement in TSC requires careful parenchymal-sparing procedures. Selective embolization of the main renal lesions should be considered as first line therapy.

A one-port pneumovesicum method in en bloc laparoscopic nephroureterectomy with bladder cuff resection is feasible and safe for upper tract transitional cell carcinoma

OBJECTIVE

• To introduce a modified method for managing the distal ureter in laparoscopic nephroureterectomy (LNU) for upper tract transitional cell carcinoma (TCC) and to evaluate the feasibility and safety of this method.

PATIENTS AND METHODS

• Six consecutive patients underwent LNU using a one-port pneumovesicum method for pathologically confirmed upper tract TCC. • Each patient was placed on the operating table in the lithotomy position and the pneumovesicum method was applied with CO(2) insufflation. Dissection was performed circumferentially through the entire detrusor muscle to disconnect the ureter from the bladder wall. A 10-mm trocar was placed into the bladder above the pubic bone. The distal ureter was occluded using a Hem-o-lok clip and pushed out of the bladder. Laparoscopic nephroureterectomy was then performed with the patient in the lateral position. • After surgery, all six patients received systemic chemotherapy and follow-up.

RESULTS

• All procedures were performed successfully. • The median (range) operating time for the complete procedure was 105 (85-140) min, and the median (range) estimated blood loss was 125 (60-230) mL. • Seven days after surgery, each patient underwent cystography, which confirmed no extravasation of urine. • None of the patients developed bladder tumour recurrence or metastatic disease during follow-up.

CONCLUSIONS

• The one-port pneumovesicum method in LNU, which is applied to manage the distal ureter and bladder cuff, is technically feasible and safe. • The method simplifies management of the distal ureter, reduces the invasiveness of the procedure and improves cosmesis.

Retroperitoneal laparoscopic upper-pole nephroureterectomy for duplex kidney anomalies in adult patients

OBJECTIVES

To present our surgical techniques and experience with retroperitoneal laparoscopic upper pole nephroureterectomy for a duplex kidney in adult patients without vesicoureteral reflux.

METHODS

A total of 32 adult patients with a duplex kidney underwent laparoscopic upper pole nephroureterectomy. A 3-port, finger- and balloon-dissecting, retroperitoneal approach was used. The upper pole renal parenchyma was divided circumferentially between the upper and lower poles using a harmonic scalpel, maintaining a margin around the upper pole parenchyma to avoid any possible injury to the lower pole functioning moiety. The urothelium of the remnant upper pole parenchyma was stripped off, and the edges of the remnant upper pole parenchyma were approximated with figure-of-8 stitches. The distal upper pole ureter was mobilized and transected at the point at which the ureter crossed anterior to the iliac vessels. Intravenous urography and renal ultrasonography were performed at 3 and 6 months postoperatively.

RESULTS

All laparoscopic operations were performed successfully without conversion to open surgery. The mean operative time was 83 minutes. The mean blood loss was 18 mL. The mean postoperative hospital stay was 7 days. No intraoperative or major postoperative complications occurred. The intravenous urography and renal ultrasound findings 3 and 6 months postoperatively demonstrated normal pyelography findings and renal function of the preserved lower pole in all patients.

CONCLUSIONS

Retroperitoneal laparoscopic upper pole nephroureterectomy is a safe and effective procedure and an excellent minimally invasive treatment option for the adult patient with a duplex kidney.

The efficacy, safety and durability of selective renal arterial embolization in treating symptomatic and asymptomatic renal angiomyolipoma

OBJECTIVE

To review the long-term outcome of selective renal arterial embolization (SAE) in treating renal angiomyolipomas (AMLs) in both elective and emergency settings.

MATERIALS AND METHODS

Between October 1988 and September 2008, 27 patients (28 renal units) were treated with SAE, either on an emergency basis for 15 (53.6%) bleeding AMLs or prophylactically for 13 (46.4%) asymptomatic high-risk (size >4.1 cm) AMLs. Six males and 21 females with a mean age of 46.3 years (range, 26-68) were followed for a mean period of 7.1 years (range, 1.3-20.2) for recurrence of symptoms, need for re-embolization, or need for renal surgery. SAE outcome was evaluated using the Kaplan-Meier method. Predictor(s) of outcome were identified with univariate analysis by log-rank test.

RESULTS

Mean size of AMLs was 10.9 cm (range, 4-30). Eight (29.6%) patients had bilateral and 19 (70.4%) had unilateral AMLs. Seventeen (60.7%) kidneys had solitary AMLs; 11 (39.2%) kidneys had multicentric AMLs. Of the 15 bleeding AMLs, 12 (80%) patients required a blood transfusion. Twenty-six (93%) AMLs were successfully embolized in the first SAE. During follow-up, four (14.8%) patients required re-embolization. Renal surgery was required in four (14.8%) patients. From the Kaplan-Meier analysis, the overall renal surgery sparing rate at 5 years was 85% (95% CI: 71-99%), whereas the single session SAE success rate at 5 years was 63% (95% CI: 42-84%). Of all the variables, only AML >10 cm was significantly associated with the subsequent need for renal surgery (P = .03). No renal malignancy was noted at final follow-up.

CONCLUSIONS

SAE is effective and durable in preventing large AMLs from bleeding, treating AMLs presenting with bleeding, and sparing the need for renal surgery.

A review of currently available vessel sealing systems

Laparoscopic surgery is rapidly expanding among urologists as a minimally invasive treatment with surgical procedures becoming increasingly challenging. Accurate haemostatis is of utmost importance in laparoscopy, as bleeding can rapidly impair the working environment conditions. We subsequently reviewed the different haemostatic tools used in laparoscopy with the focus on ultrasonic dissectors and electrothermal bipolar vessel sealer (EBVS). Briefly, there is a wide variety of haemostatic tools currently available in laparoscopy, all with their inherent advantages and limitations. The comparison of ultrasonic dissectors and EBVS shows that both systems are very attractive with similar physical properties concerning thermal spread and bursting pressure of vessels sealed. It has to be noted, however, that EBVS can handle vessels of up to 7 mm. In conclusion, haemostatic tools constitute a rapidly evolving domain with devices being developed which cause less thermal spread, while being more precise and faster. This evolution should finally allow more complex laparoscopic surgical procedures.

Retroperitoneal robotic renal surgery: technique and early results

We describe a robotic retroperitoneal approach to renal surgery, optimized in porcine and cadaveric models, and applied to human patients. A retroperitoneal approach for robotic kidney surgery was developed in nonsurvival porcine and a fresh cadaver models, and then utilized in ten patients (three partial nephrectomy, three radical nephrectomy, two simple nephrectomy, one pyeloplasty, one cryoablation). Retroperitoneal access was successfully achieved for robotic renal procedures in six pigs and a human cadaver. Ten human patients (mean age 56 years, range 36-72 years) then underwent a successful retroperitoneal approach for robotic renal surgery. Mean console time was 166 (120-300) min. Mean blood loss was 82 (50-100) ml and average hospital stay was 2.6 (1-5) days. Pathology demonstrated clear cell renal cell carcinoma (four), papillary renal cell carcinoma (two), and xanthogranulomatous pyelonephritis (two). One patient with xanthogranulomatous pyelonephritis required open conversion for failure to progress due to dense adhesions. A retroperitoneal approach is a safe and feasible alternative to a transperitoneal approach for robotic renal surgery, including radical nephrectomy, partial nephrectomy, pyeloplasty, and cryoablation.

Hemostatic techniques during laparoscopic partial nephrectomy

PURPOSE OF REVIEW

To review the current techniques and technologies being used for hemostatic control during laparoscopic partial nephrectomy.

RECENT FINDINGS

Laparoscopic nephron-sparing surgery has become more common for the treatment of renal masses. With increasing experience, the indications for nephron sparing are increasing. Despite the increased use of these techniques in high-volume centers, however, more widespread application has been limited because of the need for advanced laparoscopic skills including the laparoscopic control of intraoperative renal bleeding. As a result, many techniques have been developed to achieve hemostasis, including conventional suture repair, tissue sealants, radiofrequency ablation, lasers, water dissection, and microwave tissue coagulation.

SUMMARY

Laparoscopic partial nephrectomy is a technically challenging procedure. Many promising techniques are being developed currently, most geared toward improved hemostasis and collecting system repair. These techniques and products have made, and will continue to make, the procedure less demanding and more universally accepted.