Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears

Nephron sparing surgery for renal tumors-comparison of off-clamp partial nephrectomy with hilar clamping

Background and Objective:

Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function.

Methods:

This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. Non clamping technique was used in 43 while clamp was applied in 22 patients. Variables studied were patients’ demographics, clinical variables, the laterality, tumors size and location, R.E.N.A.L nephrometry score, blood loss, tumor histology and surgical margins. Patients’ renal function (serum creatinine and eGFR) were determined pre-operatively, at 3 and 12 months follow up. Data was analyzed on SPSS v. 22.

Results:

Both the groups were comparable with regards to pre-operative renal function. Mean radiological size of tumor was 4.71±1.31 and 3.81±1.0 (0.003) in two groups respectively. Mean R.E.N.A.L nephrometry score was 6.1±1.5 in off-clamp group compared to 7.05 ± 1.7 in clamp group (p=0.04). No statistically significant difference was found in operative duration, blood loss, positive surgical margins and intra/ peri-operative complications. At three months and one year, renal function was better preserved in non-clamp group compared to clamp group (p=0.001 and 0.007 respectively).

Conclusion:

Off clamp open partial nephrectomy is safe and feasible option leading to less decline in renal function.

Zero ischaemia laparoscopic nephron-sparing surgery by re-suturing

AIM OF THE STUDY

To report a pre-suture technique in laparoscopic nephron-sparing surgery (LNSS), which could help reduce and even avoid ischaemia for the treatment of renal cell carcinoma.

MATERIAL AND METHODS

Between January and June 2013 we treated 14 patients presenting with renal tumours. The mean age was 46 years and average tumour size was 2.4 cm in diameter determined by computed tomography (CT). All the patients were treated with LNSS by pre-suturing the resection.

RESULTS

In 13 out of the 14 cases, no clamping was needed during the whole surgery processes, i.e. zero ischaemia was achieved. In the other case, the renal artery was clamped for only 150 seconds due to suture avulsion. The mean operating time was 75 minutes (range 50 to 110 minutes) and mean blood loss was 60 ml (range 30 to 200 ml). After removal of the drain 2-3 days after surgery, the average postoperative hospital stay time was four days. The surgery had only a minor effect on the renal function. No case of urinary leakage or postoperative bleeding occurred. Postoperative pathological reports showed that the tumours were resected completely with negative surgical margins for all cases. There were no signs of recurrence on follow-up CT performed 1-6 months after surgery.

CONCLUSIONS

The pre-suture technique in LNSS reported here required zero or minimal ischaemia time and hence avoided renal ischaemia-reperfusion injury. This surgical technique could be a feasible surgical option for treatment of small, exophytic and peripheral renal tutors.

Experience of laparoscopic partial nephrectomy using a kidney grasper in selective cases

OBJECTIVE

To evaluate the feasibility of regional cramp in laparoscopic partial nephrectomy, we performed partial nephrectomy using a kidney grasper that enabled the application of ischemia to a limited region of the kidney.

MATERIALS AND METHODS

The subjects were 5 renal cell carcinoma patients. The mean tumor diameter was 15 mm. There were 2 male and 3 female patients. A transperitoneal approach was used in all cases. Following the standard procedure of laparoscopic partial resection, the hilum of the kidney was confirmed and treated to prepare for rapidly applying clamping with forceps. Tumor resection and suture were then performed under partial warm ischemia using a kidney grasper.

RESULTS

Surgery could be completed in 4 patients using this method. In the remaining patient, control of bleeding was considered difficult during tumor resection after applying partial ischemia, and so the procedure was switched to renal artery clamping using bulldog forceps. In the 4 patients in whom a kidney grasper was used, the mean partial warm ischemia time was 23.6 minutes (range, 23-25 minutes), and the mean blood loss was 110 mL (range, 20-260 mL).

CONCLUSIONS

This procedure may be a useful option in ischemia for partial nephrectomy.

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.

Impact of "non-clamping technique" on intra- and postoperative course after laparoscopic partial nephrectomy

INTRODUCTION

The use of kidney warm ischaemia during laparoscopic partial nephrectomy (LPN) may lead to damage of renal vessels and kidney failure. Laparoscopic partial nephrectomy done without clamping the renal pedicle is feasible and may be beneficial for the postoperative course.

AIM

To compare intra- and postoperative course in patients undergoing LPN with and without kidney warm ischaemia.

MATERIAL AND METHODS

The material comprises 38 consecutive patients, who underwent LPN in our department during the years 2008-2009. In all cases renal vessels were identified and dissected at first, then resection of the tumour was done. Warm ischaemia was used only in case of difficulties with identification of tumour margin or with the management of bleeding. Out of 38 operations 13 were done without clamping the renal pedicle (group 1) and in the remaining 25 warm ischaemia was applied (group 2).

RESULTS

Mean dimension of resected tumours in groups 1 and 2 was 31 mm and 33 mm respectively (p > 0.05), while parameters of intra- and postoperative course differed significantly between the groups: mean blood loss - 135 ml vs. 354 ml (p < 0.05), time of surgery - 72.6 min vs. 132.2 min (p < 0.05), postoperative drain leakage - 290 ml vs. 504 ml (p < 0.05), postoperative hospital stay - 3.1 days vs 5.3 days (p < 0.05). In all patients baseline creatinine levels were normal while after surgery creatinine elevation over the upper limit was found in groups 1 and 2 in one and in 6 patients respectively (p < 0.05).

CONCLUSIONS

Laparoscopic resection of kidney tumour without warm ischaemia is feasible and beneficial in pre- and intraoperatively selected cases. Bleeding from renal parenchyma, which requires renal pedicle clamping, may seriously deteriorate intra- and postoperative course in patients undergoing laparoscopic partial nephrectomy.

Selective renal parenchymal clamping in retroperitoneal partial nephrectomy

OBJECTIVE

Herein, we report our experience with retroperitoneoscopic partial nephrectomy (RPN) without hilar occlusion by the use of a laparoscopic clamp to induce selective regional ischemia.

METHODS

A 48-year-old woman was referred for a left upper polar renal mass, which was suspected to be malignant. The contralateral kidney revealed severe atrophy, and she was scheduled to undergo RPN using a laparoscopic clamp to induce selective regional ischemia. At first, the kidney is fully mobilized within the retroperitoneal space. Thereafter, the laparoscopic clamp is applied directly to the kidney, about 1 cm below the resection line. When closed, the renal parenchyma is compressed, so that blood supply to the tumor is interrupted. The preserved portion of the kidney is perfused normally, and it is possible to remove the tumor in a bloodless field without involving warm ischemia.

RESULTS

Renal hilar clamping was avoided, with minimal estimated blood loss. There was no perioperative complication, and the final pathology revealed a hemorrhagic renal cyst. The radioisotope absorption of the enucleated kidney was well maintained, except for the marginal area of the enucleated site. The renogram pattern was found to be equivocal when compared with the preoperative renogram.

CONCLUSION

Regional renal parenchymal clamping during RPN can be safely and effectively used to create a bloodless operative field. Moreover, our preliminary experience demonstrates that this technique facilitates maximal nephron-sparing surgery for patients with an anatomically or functionally solitary kidney, without involving warm ischemia.

Laparoscopic approach to small renal mass

With maturing functional and oncologic outcomes data, open partial nephrectomy (OPN) has become the standard of care for T1a renal tumor. Laparoscopic approach can provide a speedier recovery with less blood loss and postoperative pain. Presuming adequate laparoscopic expertise, laparoscopic partial nephrectomy can provide equivalent oncologic outcome as for OPN albeit with higher urologic complications rate and longer warm ischemia time. With refinement of technique and use of robotic assistant, the shortcomings of laparoscopic approach can be further reduced. This article is a mini-review on the current status of laparoscopic approach to partial nephrectomy in the management of small renal mass.

Energy sources for laparoscopic partial nephrectomy--critical appraisal

Laparoscopic partial nephrectomy (LPN) has emerged as a viable alternative for the conventional open nephron-sparing surgery (NSS). So far, an adequate renal parenchymal cutting and hemostasis, as well as caliceal repair remains technically challenging. Numerous investigators have developed techniques using different energy sources to simplify the technically demanding LPN. Herein we review these energy sources, discussing perceived advantages and disadvantages of each technique.

Evaluation of costs and morbidity associated with laparoscopic radiofrequency ablation and laparoscopic partial nephrectomy for treating small renal tumours

OBJECTIVE

To compare the costs and morbidity of laparoscopic radiofrequency ablation (LRFA) and laparoscopic partial nephrectomy (LPN) for treating small localized renal tumours.

PATIENTS AND METHODS

We retrospectively analysed the outcomes of 88 patients treated at our institution for a renal tumour either by LPN (50) or LRFA (38) between March 2000 and May 2006. Patients with multiple tumours, combined LRFA and LPN, and those who had other simultaneous surgical procedures were excluded. Clinical variables and outcomes were analysed for each patient. Direct cost data were available for 40 patients treated with LPN and 14 with LRFA. Continuous and categorical variables were compared using an independent t-test and chi-square test, respectively.

RESULTS

The tumour size was comparable in each group; patients in the LRFA group had more comorbidities (P = 0.01) and a higher overall mortality rate (P = 0.01) but no patient died from cancer. Operative duration, estimated blood loss and length of stay were significantly shorter in the LRFA group but there was no difference in complication rate. LRFA was less costly than LPN ($6103 vs $6808, P = 0.3) but not statistically significantly. The cost savings from the shorter operative duration and length of stay were reduced by the cost of probe. With a median follow-up of 20 months there was no difference in oncological outcome.

CONCLUSION

Patients undergoing LRFA tend to be older and have more comorbidities than those treated with LPN. The cost is minimally lower for LRFA, secondary to the added cost of the probe. LRFA might be a good alternative treatment in patients at higher risk of surgical complications, but LPN provides good results when done by an experienced surgeon.

Laparoscopic liver biopsy using cup-shaped punch biopsy forceps and argon beam coagulator in children

Needle liver biopsy is insufficient for measuring enzyme activity in liver tissue in child cases of intrahepatic cholestasis because the biopsy specimen obtained is too small. This study was undertaken to validate the feasibility of a new, relatively non-invasive laparoscopic liver biopsy technique combining the use of laparoscopic cup-shaped punch biopsy forceps (CPBF) and an argon beam coagulator (ABC) handpiece for the diagnosis and examination of liver enzyme activity in cases of intrahepatic cholestasis in children. The authors performed laparoscopic liver biopsy with the combined use of laparoscopic CPBF and an ABC handpiece in 10 children aged 4 months to 9 years old. Two 5-mm trocars were inserted in each patient after their abdomens had been filled with carbon dioxide gas at a pressure of 8 mmHg. Four to five specimens (each: 0.5 cm(3) in size) were taken at the anterior edge of the left lobe of the liver using laparoscopic CPBF. ABC was sprayed on to the cut liver surface to achieve hemostasis. The duration of the laparoscopic procedure ranged from 25 to 64 (44 +/- 12.8) min. The maximum intraoperative hemorrhage from the biopsied liver bed was 30 ml. The bleeding was easily controlled using ABC for about 1 min. There were no cases of postoperative bleeding, bile leakage from the cut surface, nor intraabdominal infection. There were also no death cases, and only one complication (hydrocele testis) was recorded. Examination by microscopy and assays of enzyme activities were performed using these biopsy specimens, which were sufficient for diagnosis in all patients. Laparoscopic liver biopsy combining the use of laparoscopic CPBF and an ABC handpiece can be performed safely, is less invasive, and provides sufficient samples for examination both by microscopy and enzyme activity assays.

Laparoscopic Partial Nephrectomy with “On-Demand” Clamping Reduces Warm Ischemia Time

OBJECTIVES

To investigate the impact of "on-demand" clamping during laparoscopic partial nephrectomy on warm ischemia time.

METHODS

We retrospectively reviewed 39 consecutive patients with renal tumors who had undergone transperitoneal laparoscopic partial nephrectomy from April 2002 to May 2006. Median tumor size was 2.3 cm. In all cases, the hilum was dissected early and extracorporeal clamping performed. The pedicle was clamped only in case of excessive bleeding, and it was released immediately after the closure of the renal defect with knot-tying sutures over Surgicel bolsters.

RESULTS

Median operative time was 120 min. Renal clamping was required in 31 of 39 patients and in this subgroup the median warm ischemia time was 9 min. Median operative blood loss was 150 ml. Eight patients required blood transfusion and among these two were converted to open surgery. Positive surgical margin was observed in one case. Renal cell carcinoma was present in 22 (54.4%) specimens. No recurrence was observed after a median follow-up of 15 mo.

CONCLUSIONS

This novel technique using extracorporeal clamping significantly decreases warm ischemia time, avoiding clamping of the pedicle in selected cases. Our study underlines the feasibility of performing laparoscopic partial nephrectomy with extracorporeal hilar clamping, allowing the shortest ischemia time ever published.

Biological Glues and Collagen Fleece for Hemostasis during Laparoscopic Partial Nephrectomy: Technique and Results of Prospective Study

PURPOSE

The aim of this prospective study was to evaluate the advantages or disadvantages of the use of fibrin glue and collagen fleece during laparoscopic partial nephrectomy.

PATIENTS AND METHODS

Two groups of patients were studied. Group A (n = 24) received parenchymal suture, whereas Group B (n = 20) received parenchymal suture with fibrin glue and collagen fleece. The two groups were similar in baseline characteristics. We evaluated patient age, size of the lesion at CT, operative time, ischemia time, and sealant technique in relation to blood loss, hospital stay, and hemorrhagic complications.

RESULTS

No significant difference was observed in perioperative parameters (P > 0.05). The mean size of lesion was 3.3 +/- 1.2 (range 1-8 cm) for group A and 3.0 +/- 1.3 (range 2-5 cm) for Group B. The mean operative time was 116 +/- 26.6 minutes (range 90-220 minutes) for group A and 130 +/- 23.5 minutes (range 90-210 minutes) for group B. The mean warm ischemia time was 28.8 +/- 5.7 minutes (range 18-60) minutes) and 35.6 +/- 6.2 minutes (range 20-52 minutes), respectively. The mean blood loss was 178 +/- 34.5 mL (range 50-400 ml) for group A and 219 +/- 44.6 mL (range 80-750 ml) for group B. The mean hospital stay was 5.9 +/- 1.2 days (range 5-8 days) for group A and 6.3 +/- 2.1 days (range 5-9 days) for group B. Four and two postoperative hemorrhage complications were observed in groups A and B, respectively.

CONCLUSION

The use of fibrin glues and collagen fleece should be considered an adjuvant, as it does not present any substantial advantages, the suture being the key point in hemostasis control. We believe that in order to improve hemostasis, the efficacy of other types of sealants should be studied, as we were not convinced by those we used.

A pilot study of ice-slurry application for inducing laparoscopic renal hypothermia

OBJECTIVE

To assess, in a pilot study, the feasibility of delivering a microparticulate ice slurry (MPS) to provide regional hypothermia, as renal cooling during laparoscopic procedures is cumbersome and inefficient.

MATERIALS AND METHODS

An ex vivo preparation was used to simulate the boundary conditions of a kidney. Four pig kidneys were placed onto a thin membrane overlying a constant temperature bath (37 degrees C) with parenchymal thermocouples. Renal surfaces were coated with MPS and temperatures recorded. In an in vivo pig model we assessed laparoscopic delivery and cooling ability of the MPS under physiological conditions. Kidneys in two pigs were laparoscopically exposed; thermocouple probes were placed throughout the kidney and the hilum was clamped. MPS was delivered through a modified 5-mm laparoscopic suction/irrigation cannula. Cortical and core body temperatures were measured.

RESULTS

In the ex vivo study, the mean (sd) initial temperature was 37.1 (0.4) degrees C; the mean time to reach 15 degrees C was 10.3 (2.6) min and the mean nadir temperature was 13.0 (1.5) degrees C. In vivo, the MPS was delivered with no technical difficulty; the mean renal unit starting temperature and core body temperature were 37.2 degrees C and 37.0 degrees C, respectively. The mean (range) time to reach 15 degrees C was 16.5 (5.5-28.6) min. The mean nadir core body temperature was 34.0 degrees C.

CONCLUSION

This initial study showed efficient and rapid induction of renal hypothermia using MPS delivered through 5-mm laparoscopic ports, with no technical difficulty. These exploratory pilot findings support further, larger scale, histopathological and renal functional investigations of topical ice slurries as a means of providing renal hypothermia in laparoscopic procedures.

Partial nephrectomy using a monopolar radiofrequency device: An animal model

OBJECTIVES

To compare the use of radiofrequency (RF) and electrocautery in partial nephrectomy without renal artery clamping for bleeding and tissue destruction.

METHODS

Sixteen adult rabbits were randomized into two groups. Partial nephrectomy using a monopolar RF device without renal artery clamping was performed in 8 rabbits (RF group) and partial nephrectomy using electrocautery was performed in the rest (cautery group). Four rabbits in each group (rabbits 1, 3, 5, and 7) were kept for follow-up, and the operated kidneys of the rest were removed for histopathologic evaluation. The tissue samples were placed in 10% formalin solution and sent to the pathology laboratory. The groups were compared in terms of bleeding and tissue destruction.

RESULTS

The mean blood loss was 3.6 +/- 1.2 mL in the RF group and 8.3 +/- 2.7 mL in the control group (P = 0.003). A rabbit in the control group died on postoperative day 3 because of bleeding. Others were followed up for 3 months postoperatively. The amount of thermal destruction was comparable between the two groups. Varying degrees of thermal destruction were observed at the cutting margins in both groups. No difference was found between the two groups in terms of the deepness of thermal injury (1 to 2 mm).

CONCLUSIONS

The findings of our experimental study showed that the use of the RF electrode in partial nephrectomy without renal artery clamping resulted in less intraoperative bleeding without differences in terms of tissue destruction.

Organ-Preserving Endoscopic Kidney Cancer Resection

OBJECTIVE

Recently, minimally invasive therapies for renal cell carcinoma have been devised to minimise operative morbidity yet achieve comparable oncologic and functional outcomes. This video summary of laparoscopic transperitoneal organ-preserving kidney cancer resection shows the procedure from the surgeon's view.

METHODS

The video and photos show the main steps of the procedure. The results of 40 transperitoneal and retroperitoneal procedures performed during 2001-2005 are discussed. Preoperative preparation includes abdominal computed tomography and ureteral catheterisation. Tumour margins were determined by laparoscopic renal ultrasonography. Vessel control was done by en bloc clamping or solitary clamping of the artery. For optimal macroscopic evaluation of the resection margins, tumour excision was solely done with cold Endoshears followed by pelvicaliceal suture repair and parenchymal closure over surgical bolsters with a biologic haemostatic agent.

RESULTS

In 40 cases, we converted to the open procedure only once. The average patients age was 53 yr and mean tumour size was 26 mm. No patient showed positive surgical margins. The mean warm ischemia time was 21 min. Final histopathology revealed renal clear cell carcinoma as the major cell type followed by papillary renal carcinoma. Two patients required blood transfusion. Estimated mean blood loss was 270 ml. Median time of hospitalisation was 6 d.

CONCLUSION

Endoscopic partial nephrectomy can be performed by experienced surgeons in selected patients. Tumour location and size and the surgeons' experience and preference are the main parameters to make the decision of the type of access.

Laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE

The technique of laparoscopic partial nephrectomy has matured significantly over the past decade and is emerging as an oncologically sound procedure for the management of small renal tumors. Methods of tumor excision as well as parenchymal reconstruction in a hemostatically controlled field have evolved to make this procedure safer. Improved techniques to minimize warm renal ischemia are being developed. Finally, methods to prevent positive surgical margins during laparoscopic surgery are crucial to a satisfactory oncologic outcome. These important technical issues, as well as the current results of laparoscopic partial nephrectomy, are discussed.

MATERIALS AND METHODS

The urologic peer-review literature related to nephron-sparing surgery was reviewed. Controversial issues with respect to the surgical approach, methods of hemostatic control, acceptable time of warm ischemia, and cooling techniques were reviewed and collated. Perioperative results from larger series of laparoscopic and open partial nephrectomy were evaluated.

RESULTS

Open nephron-sparing surgery for renal tumors < or =4 cm has cancer control equivalent to that of open radical nephrectomy. Evidence is now emerging that laparoscopic partial nephrectomy will provide similar oncologic results, although clinical follow-up is still early. Blood loss, postoperative pain, and convalescence seem to be favor the laparoscopic approach. Complication rates, primarily postoperative bleeding and urine leak, may be higher than for open nephron-sparing surgery. Methods of laparoscopic hemostatic control favor soft vascular clamping for larger tumors that are more endophytic and central. Smaller exophytic lesions may be managed without renal vascular control using a variety of coagulative and hemostatic tools. Data related to warm renal ischemia suggest that the time used for tumor excision and renal reconstruction should be 30 minutes or less. Techniques for laparoscopic renal cooling are being developed.

CONCLUSIONS

Laparoscopic nephron-sparing surgery is a technique in evolution but with a promising outlook. The urologic peer-review literature reflects an exponential growth in interest, which suggests that this minimally invasive approach is practical and may benefit our patient population so as to allow them to return to normal healthy living more quickly.

Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system

OBJECTIVES

To develop and assess the feasibility of laparoscopic partial nephrectomy performed using the daVinci robotic system.

METHODS

Between November 2002 and August 2003, 13 patients with solid or suspicious cystic renal masses underwent robotic-assisted laparoscopic partial nephrectomy. In 8 cases, an intra-arterial catheter was inserted for renal cooling before occlusion of the renal artery. The remaining 5 patients underwent partial nephrectomy after the renal hilum had been clamped. Tumor excision and intracorporeal suturing were performed entirely with telerobotics. The perioperative data and pathologic results were retrospectively reviewed.

RESULTS

The mean lesion diameter was 3.5 cm (range 2.0 to 6.0). The mean operative time was 215 minutes (range 130 to 262), and the mean blood loss was 170 mL (range 50 to 300). The mean warm ischemia was 22 minutes (range 15 to 29), and the mean cold ischemia time was 33 minutes (range 18 to 43). The length of hospital stay averaged 4.3 days (range 2 to 7). The resected lesions included renal cell carcinoma in 10, oncocytoma in 2, and a complex renal cyst in 1. In 1 case, a positive margin occurred despite negative frozen sections; laparoscopic nephrectomy was performed and showed no residual tumor. One patient experienced postoperative ileus. At 2 to 11 months of follow-up, no recurrence had been observed.

CONCLUSIONS

Robotic-assisted partial nephrectomy is feasible. Robotic partial nephrectomy can be safely performed using a transperitoneal or retroperitoneal approach. A second scrubbed assistant is mandatory to provide assistance using conventional laparoscopic instruments with this technique.

Laparoscopic partial nephrectomy: Is it advantageous and safe to clamp the renal artery?

OBJECTIVES

To compare the outcomes of laparoscopic partial nephrectomy (LPN) performed with and without vascular clamping and to evaluate the impact of clamping on postoperative renal function.

METHODS

A total of 45 patients underwent LPN, 29 with and 16 without vascular occlusion. The two groups were compared regarding complication rates, blood loss, conversion rates, operative time, mean tumor size, and incidence of positive margins. Renal function was evaluated by postoperative dimethyl mercaptosuccinic acid scans.

RESULTS

The mean blood loss was lower when vascular clamping was applied (320 versus 510 mL, P <0.05) than when it was not. The conversion rates were similar (10.3% versus 12.5%), and the mean operative time was shorter in the nonclamped group (115 versus 126 minutes). Urinary leakage occurred in 2 patients, 1 from each group. The mean tumor diameter was 3.2 cm in the clamped and 1.9 cm in the nonclamped group (P <0.05). In 2 patients (12.5%) in the nonclamped and 1 patient (3.4%) in the clamped group, the surgical margins were focally positive for tumor. The mean warm ischemia time was 28 minutes, and dimercaptosuccinic acid scans performed in 18 patients showed normal ipsilateral renal function (mean relative function 48%).

CONCLUSIONS

LPN without vascular clamping is feasible in selected cases. However, clamping of the artery seems to be associated with reduced blood loss and a lower incidence of positive margins. Moreover, according to the postoperative dimercaptosuccinic acid scan findings, limited warm ischemia does not seem to result in permanent renal damage. We suggest that clamping of the renal artery should be considered during LPN, even for very small, superficial tumors.

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

OBJECTIVES

To evaluate the feasibility and clinical efficacy of retroperitoneal laparoscopic nephron-sparing surgery for renal tumors.

METHODS

Between June 2002 and February 2004, 11 cases of renal benign tumor and 21 cases of renal malignant tumor underwent enucleation of the tumor and wedge resection of the tumor through retroperitoneal laparoscopy, respectively. Tumor resection and hemostasis were mainly achieved by harmonic scalpel. Follow-up studies were performed with an evaluation using renal spiral computed tomography.

RESULTS

All procedures were technically successful. The mean operating time was 70 minutes for enucleation and 96 minutes for wedge resection. The mean estimated blood loss was 35 mL for enucleation and 65.5 mL for wedge resection. The mean hospital stay after surgery was 6.5 days. No intraoperative complications occurred. The pathologic examination confirmed renal cell carcinoma in 21 patients and angiomyolipoma in 11. The pathologic stage was pT1a in the 21 patients with renal cell carcinoma. All resected tumor specimens had negative surgical margins for cancer. No local recurrence or trocar site metastasis was observed during a mean follow-up period of 13 months.

CONCLUSIONS

Our results indicate that retroperitoneal laparoscopic nephron-sparing surgery represents a feasible option for patients with localized renal tumors. This procedure could offer precise and complete tumor excision while minimizing morbidity, improving cosmesis, and shortening convalescence.

Laparoscopic Nephron Sparing Surgery: Evolution in a Decade

OBJECTIVE

To present our experience with laparoscopic nephron sparing surgery (NSS) over a decade.

METHODS

Seventy-eight patients underwent NSS since 1994. Two techniques were used-partial nephrectomy without ischemia (group 1) in 29 patients, and with ischemia (group 2) which was in cold or warm ischemia in 24 and 25 patients respectively. The mean tumour size was 1.97 and 2.2 cm in groups 1 and 2 respectively. Renal reconstruction evolved in our hands during this period. We changed many technical details and now we depend more on clips for securing the sutures rather than free hand knotting.

RESULTS

The mean operative time was 162 and 216 minutes in groups 1 and 2 respectively. Mean ischemia time for patients with cold and warm ischemia was 44.9 and 33.8 minutes respectively. 3 patients in group 2 were converted to open surgery. Mean blood loss was 254 and 212 ml for group 1 and 2 respectively with two major bleedings in group 2. Minor intra-operative complication occurred in 3 patients, and major and minor postoperative complication in 15 patients. At a mean follow-up of 23.9 and 12.2 months for groups 1 and 2 respectively there was no recurrence.

CONCLUSION

Warm and cold ischemia have widened the indications for laparoscopic NSS to more complex tumours and allow renal reconstruction with acceptable complication rate.

ASSESSMENT OF SURGICAL MARGINS IN RENAL CELL CARCINOMA AFTER NEPHRON SPARING: A COMPARATIVE STUDY

PURPOSE

We compared the status of the peritumoral parenchyma after open and laparoscopic nephron sparing surgery for renal cell carcinoma.

MATERIALS AND METHODS

The records of 64 consecutive patients who underwent nephron sparing surgery for renal cell carcinoma of 4 cm or less were reviewed retrospectively. Patients in group 1 underwent open retroperitoneal surgery (1998 to 2000) and patients in group 2 underwent laparoscopic (transperitoneal or retro peritoneal) surgery (2001 to March 2004). A single pathologist was employed to analyze the specimens, and comparative analysis included examination of tumor size, weight, histological cell type, intraoperative histological biopsies and margin status.

RESULTS

The 2 groups were comparable in terms of clinical data, and mean lesion size was 31.4 mm in group 1 and 32 mm in group 2. Positive margins were found in 1 of 30 patients in group 1 and in 1 of 34 in group 2 (p = 0.9). An analysis of margins was performed by taking measurements at the minimum and maximum points of the section. The minimum mean measurement was 2 mm in group 1 and 2.08 mm in group 2 (p = 0.75). The maximum mean measurement was 4.56 mm in group 1 and 5.2 mm in group 2 (p = 0.09). The difference between minimum and maximum margin thickness was 2.56 mm in group 1 and 3.16 mm in group 2 (p = 0.04). Mean followup for group 1 was 50 months (range 30 to 72) and 16 months (range 2 to 35) for group 2. One local recurrence was recorded in group 1 and treated with radical nephrectomy, while no recurrence was recorded in group 2.

CONCLUSIONS

In this study we further confirmed the efficiency of resectioning lesions using laparoscopy. In our experience there is no difference between the 2 procedures in terms of efficient surgical margins. However, despite these encouraging results it is necessary to obtain more extensive followup data, which will allow us to be more specific in reporting on laparoscopic margin quality.

Laparoscopic partial nephrectomy using a microwave tissue coagulator for treating small peripheral renal tumors

BACKGROUND

Laparoscopic partial nephrectomy has been recently applied as a minimally invasive procedure. Several non-ischemic operation devices in partial nephrectomy have been developed. However, the problem related to maintenance of renal homeostasis remains. We investigated the efficacy and safety of a microwave tissue coagulator in laparoscopic partial nephrectomy.

METHODS

Between April 2001 and February 2003, eleven patients with small renal tumors underwent laparoscopic partial nephrectomy using a microwave tissue coagulator. Seven patients underwent hand-assisted laparoscopic procedure and 4 pure laparoscopic procedure.

RESULTS

The mean tumor size on preoperative CT scan was 2.5 cm (range: 2.0 to 4.0 cm), the mean operative time was 307 minutes (range: 160 to 580 minutes), and the mean estimated blood loss was 154.4 ml (range: 50 to 1,140 ml). The microwave tissue coagulator well controlled the renal bleeding and maintained renal function. All patients safely underwent partial nephrectomy without inducing renal ischemia. A complication of urine leakage was recognized in only one patient with hypoproteinemia caused by nephrotic syndrome.

CONCLUSIONS

Laparoscopic partial nephrectomy using a microwave tissue coagulator was a useful method for achieving homeostasis, and was less invasive for treating small renal tumors.

Laparoscopic partial nephrectomy: contemporary technique and results

An increasing number of incidental small renal masses are being detected currently. In select patients, nephron-sparing surgery affords excellent oncologic outcomes with preservation of renal function. With the current trend towards minimally invasive surgery, development of a reliable laparoscopic partial nephrectomy technique has become a key issue. Over the past 4 years, the senior author has performed over 300 laparoscopic partial nephrectomies at the Cleveland Clinic. Herein we present our current technique and review contemporary results from the urologic literature.

Laparoscopic Nephron-Sparing Surgery for a Renal Mass: 1-Year Minimum Follow-Up

BACKGROUND AND PURPOSE

Because of the explosion of laparoscopy in urology coinciding with the excellent results of open nephron-sparing surgery (NSS) for small renal masses, laparoscopic NSS has become an alternative to an open surgical approach. We report our results with laparoscopic NSS in patients who have had a minimum of 1 year of follow-up.

PATIENTS AND METHODS

All consecutive laparoscopic partial nephrectomies from November 1998 through February 2002 were assessed. The mean patient age, body mass index, and American Society of Anesthesiology score were 57.1 years, 28.5 cm/kg2, and 2.0, respectively. The procedures were performed using hand-assisted (N = 28) or standard (N = 12) laparoscopic techniques. Hospital records were reviewed in order to obtain operative, perioperative, and follow-up data.

RESULTS

The median operating room time, estimated blood loss, and hospital stay were 184 minutes, 300 mL, and 2.0 days, respectively. No patients were converted to an open surgical procedure. Four patients (10%) required a blood transfusion, and one (2.5%) had a postoperative urinoma. The mean tumor size was 2.3 cm. Twenty-nine lesions were renal-cell carcinoma, and 11 were benign. With a mean CT scan follow-up of 100.0 weeks, there has not been any recurrence of renal-cell carcinoma.

CONCLUSION

Laparoscopic NSS can be performed with acceptable complication rates, which will continue to decrease as newer methods of controlling hemostasis are developed. Although follow-up is fairly short, no renal-cell carcinoma recurrences have appeared. At this point in time, the oncologic efficacy of a laparoscopic approach appears to mirror that of the open surgical technique.

LAPAROSCOPIC PARTIAL NEPHRECTOMY: EFFECT OF WARM ISCHEMIA ON SERUM CREATININE

PURPOSE

Laparoscopic partial nephrectomy (LPN) has been shown to be a safe and effective option for small renal tumors. However, limited data are available regarding the effect of warm ischemic time on postoperative renal function. We assessed the effect of variable durations of warm ischemia on long-term renal function in patients undergoing LPN.

MATERIALS AND METHODS

A total of 118 patients with a single, unilateral, sporadic renal tumor and normal contralateral kidney underwent LPN from August 1998 to November 2002. Patients were divided into 3 groups based on warm ischemic time, namely group 1-no renal occlusion in 42, group 2-warm ischemia less than 30 minutes in 48 and group 3-warm ischemia greater than 30 minutes in 28. All 3 groups were assessed for changes in serum creatinine 6 months after LPN. Additionally, renal remnants were examined with cross-sectional imaging.

RESULTS

At a median followup of 28 months (range 6 to 56) median creatinine had not statistically increased postoperatively. None of the 118 patients progressed to renal insufficiency or required dialysis after LPN.

CONCLUSIONS

Based on postoperative serum creatinine warm ischemia time up to 55 minutes does not significantly influence long-term renal function after LPN. Thus, during LPN efforts to minimize warm ischemia are important but they should not jeopardize cancer control, hemostasis or collecting system closure.

Laparoscopic partial nephrectomy for renal tumor: Nagoya experience

OBJECTIVES

To clarify the indication for a vascular clamp during laparoscopic partial nephrectomy, the clinical results of 17 patients who underwent the procedure for small renal tumors were reviewed.

METHODS

Seventeen patients with renal tumors were enrolled in our laparoscopic partial nephrectomy program between October 1999 and November 2003. During laparoscopy, a vascular clamp was used to remove the tumor mass and suture the incised renal parenchyma and urinary collecting system in 8 patients who had less-than-1-cm-thick renal parenchyma between the mass and the renal sinus or calices. In the remaining 9 patients, who had 1-cm-or-more-thick renal parenchyma between the mass and sinus or calices, renal bleeding was controlled using ultrasonic scissors, gauze tampon, argon beam coagulator, and fibrin glue.

RESULTS

Sixteen patients were successfully treated with laparoscopy; one required conversion to open surgery because of uncontrollable bleeding. The average operative time was 4.5 hours, and average estimated bleeding volume was 301 mL. In the 8 patients requiring vascular clamping by forceps, the average ischemic time was 25 minutes. In all patients, the tumor mass was completely removed with negative surgical margins, and renal function was preserved. Three patients had prolonged urinary leakage for a mean of 21 days.

CONCLUSIONS

Laparoscopic partial nephrectomy offers many advantages, including surgery that is both nephron sparing and minimally invasive. A vascular clamp was indicated for patients with less-than-1-cm-thick renal parenchyma between the tumor mass and renal sinus or calices.

DEVELOPMENT OF A RENAL TUMOR MIMIC MODEL FOR LEARNING MINIMALLY INVASIVE NEPHRON SPARING SURGICAL TECHNIQUES

PURPOSE

New laparoscopic partial nephrectomy and tumor ablation techniques are continuously being developed and evaluated in large animal models. However, to our knowledge no reliable renal tumor model exists to evaluate procedure efficacy. We developed and assessed the reliability of a tumor mimic model to serve as a training tool for minimally invasive kidney surgery.

MATERIALS AND METHODS

An agarose based model was created using a mixture of 3% agarose, 3% cellulose, 7% glycerol and 0.05% methylene blue. It is liquid when heated, but solidifies after cooling to physiological temperatures. The agar was injected (0.7 cc) into porcine renal parenchyma to make endophytic or completely intraparenchymal lesions. Three-dimensional ultrasound images of the lesions were obtained during initial development to ensure spherical lesions. A group of 20 lesions was initially placed in an ex vivo setting to assess size consistency and define baseline impedance characteristics. An additional 20 tumor mimics each were established in a laparoscopic model in a laparoscopic box trainer and an in vivo laparoscopic model. They were ablated with a temperature based radio frequency generator to assess impedance characteristics but the efficacy of ablation was not assessed. The in vivo model consisted of placing the agar lesion percutaneously under direct laparoscopic vision.

RESULTS

The agarose mixture was easily injected and readily visible on ultrasound as hyperechoic distinct lesions. Lesions had a mean size of 10.8 +/- SD 1.3 mm on ultrasound and 10.9 +/- 1.2 mm grossly. The impedance of normal renal parenchyma and unablated lesions was similar. Mean lesion size in the ex vivo model after radio frequency ablation was 9.8 +/- 2.0 mm on ultrasound, which was similar to the gross mean lesion size of 9.7 +/- 1.0 mm. Similar results were obtained for the in vivo model with a mean size of 10.1 +/- 2.1 and 10.4 +/- 1.5 mm, respectively. The lesions were easily identified grossly as blue solid lesions that replaced renal parenchyma.

CONCLUSIONS

The described renal tumor mimic model reproducibly creates ex vivo and in vivo porcine kidney lesions. Lesion size and impedance do not change with the application of radio frequency energy. This model should be a valuable adjunct in the development, assessment and teaching of novel, nephron sparing, minimally invasive surgical techniques.

Changing Concepts in the Surgical Management of Renal Cell Carcinoma

The foundations of the generally accepted principles underlying the surgical management of renal cell carcinoma (RCC) were best annunciated in 1969 by Robson in his classic description of the radical nephrectomy [J Urol 1969;101;297]. Since then, much has changed in our understanding of the basic biology and genetics of kidney cancer, advances in renal imaging and clinical staging have led to the increased detection of incidental, lower stage, organ-confined tumors more amendable to expanded surgical options, surgical techniques themselves have evolved, and surgical equipment technology has advanced to make possible new methods of managing renal tumors in situ. Thus, the management of both localized and metastatic RCC has changed dramatically in the last 20 years, predicated on these major advancements in renal imaging, surgical techniques, and the development of effective immunotherapies for advanced disease. In this review, the evolution in thinking regarding the tenets of the radical nephrectomy will be examined, including the necessity for removal of the entire kidney, the possibility of sparing the adrenal gland, when and how extensive a lymphadenectomy should be performed, the development of laparoscopic and percutaneous nephron-sparing surgery using ablative technologies, and the role of nephrectomy and metastasectomy in patients with metastatic RCC. Here, we review current concepts and outcomes on the surgical management of RCC to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

The use of a fibrin tissue sealant during laparoscopic partial nephrectomy

OBJECTIVE

To assess the feasibility and efficacy of commercially available fibrin tissue sealant as a haemostatic agent and collecting-system sealant during hand-assisted laparoscopic partial nephrectomy (LPN).

PATIENTS AND METHODS

Fifteen consecutive patients underwent LPN for enhancing renal masses suspicious for renal cell carcinoma via a transperitoneal approach and with the use of a hand-assistance device. Monopolar electrocauterization and argon-beam coagulation were initially used to slow bleeding from the resection site. Through a laparoscopic applicator, Tisseel(TM) fibrin sealant (Baxter Inc., Deerfield, IL) was applied to the transected partial nephrectomy bed while the surgeon's hand maintained adequate compression and partial haemostasis. No further haemostatic measures were required in any patient; the patients were evaluated for acute and delayed bleeding or urinary extravasation.

RESULTS

In all cases electrocauterization and argon-beam coagulation followed by the application of Tisseel was successful in obtaining strict haemostasis of the surgical bed, with no evidence of bleeding during or after surgery on immediate and extended follow-up. In addition, there was no evidence during or after surgery of any urinary leak. There were no immediate or delayed complications in any of the patients; a short-term outpatient follow-up (12-60 weeks) revealed no additional problems.

CONCLUSIONS

Conventional haemostatic measures of electrocauteriztion and argon-beam coagulation combined with commercial fibrin sealant allows successful haemostasis during LPN. In addition to haemostatic properties, fibrin sealants appear to have sealing properties that may help to prevent complications of urinary leakage by helping to seal or close the small defects in the urinary collecting system. The use of this compound may facilitate the ability of the urological laparoscopist during LPN.

Changing Management of Organ-Confined Renal Masses

BACKGROUND AND PURPOSE

Rapid evolution of laparoscopic and ablative techniques is changing the approach to renal masses. We evaluated our approach to managing renal masses in light of newly available technology.

PATIENTS AND METHODS

The records for all patients who underwent treatment for a renal mass between January 2000 and July 2002 at UT Southwestern Medical Center were reviewed for patient demographics, operative details, and pathology results. There were 180 patients with 190 masses. Of the 190 masses, 97 were <4 cm, 47 were between 4 and 7 cm, and 46 were >7 cm.

RESULTS

Most tumors >7 cm were managed with open radical nephrectomy (RN). For patients with masses between 4 and 7 cm, the majority were treated with laparoscopic RN, while 21% were treated by open partial nephrectomy (PN). Tumors <4 cm were treated with the widest variety of approaches. Open PN was the most commonly utilized, followed by laparoscopic RN and percutaneous ablation. The number of laparoscopic and percutaneous ablative procedures increased significantly with time, from none in the first year to 13% (7/55) and 29% (16/55) in the last year, respectively. Benign pathology was found in 20%, 17%, and none of lesions <4, 4 to 7, and >7 cm, respectively.

CONCLUSIONS

The addition of laparoscopy and ablative technologies has increased the treatment options for patients with renal masses. We propose a treatment algorithm that incorporates ablative technologies and favors parenchyma-sparing approaches for small lesions.

HAND ASSISTED LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR PERIPHERAL AND CENTRAL LESIONS: A REVIEW OF 30 CONSECUTIVE CASES

PURPOSE

We reviewed our first 30 hand assisted laparoscopic partial nephrectomies and compared the results of 8 centrally located vs 22 peripherally located tumors.

MATERIALS AND METHODS

Tumors were classified by computerized tomography as central (less than 5 mm from the pelvicaliceal system or hilar vessels) or peripheral. The hand assisted technique consisted of mobilization and manual parenchymal compression without vascular occlusion or ureteral stent placement. Argon beam coagulation and a fibrin glue bandage were used for hemostasis.

RESULTS

Mean tumor size was 2.6 cm (range 1.0 to 4.7). Mean operative time was 199 and 271 minutes, and estimated blood loss was 240 and 894 ml for peripheral and central lesions, respectively. No case required open conversion. The final diagnoses were renal cell carcinoma in 21 patients, angiomyolipoma in 4, benign or hemorrhagic cyst in 3 and oncocytoma in 2. Initial positive margins were found in 5 of 30 specimens (16.7%) (1 central and 4 peripheral) and all final resection margins were negative. Four central (50%) and 2 peripheral (9.1%) tumor cases required transfusion. Drain creatinine was elevated in 6 patients (20%) postoperatively, of whom 3 had a central and 3 had a peripheral lesion. All responded to conservative management except 1 patient (3.3%) who required stent placement. Postoperative bleeding in a central tumor case required transfusion of 4 units. There were no short-term local recurrences and 1 patient had an asynchronous tumor.

CONCLUSIONS

Hand assisted laparoscopic partial nephrectomy is safe with excellent immediate cancer control. Careful dissection and frozen section analysis are mandatory to ensure a negative tumor margin. Blood loss and transfusion rates were higher in patients with centrally located tumors and renal hilar vascular control should be considered for central lesions.

Applications of laparoscopic surgery in urology: impact on patient care

From its first use as a diagnostic tool, urologic laparoscopy has developed into a complex therapy for both benign and malignant disease. Most procedures are still performed at large centers with experienced laparoscopists but nonacademic urologists are starting to gain the necessary training and skills. With the clear advantage that laparoscopy shows over open procedures in terms of decreased perioperative morbidity and quicker recovery times, patients are increasingly asking for this approach. The urologic community must meet this challenge and train future urologists to meet the expected demand.

Emerging Nephron Sparing Treatments for Kidney Tumors: A Continuum of Modalities From Energy Ablation to Laparoscopic Partial Nephrectomy

PURPOSE

The current global medical trend toward minimally invasive treatment for various tumors has generated special interest in several minimally invasive options in the management of kidney tumors. We discuss the role of nephron sparing surgery by less invasive options than the time-honored partial nephrectomy, and the current multitude of energy based tumor ablative methods.

MATERIALS AND METHODS

We searched the English literature following the introduction of nephron sparing surgery, with special attention to various emerging minimally invasive surgical and ablative alternatives.

RESULTS

Laparoscopic partial nephrectomy can be performed safely following the surgical oncology principles established by open partial nephrectomy. Initial results from the various energy based modalities, most notably cryoablation, indicate that high local control rates can be achieved. However, caution is advised since viable tissue has been observed after minimally invasive ablative therapies. Available data, while promising, are still lacking for long-term followup.

CONCLUSIONS

Compared to open partial nephrectomy the laparoscopic approach offers similar cancer-free survival rates. However, the procedure requires highly skilled surgeons. Of the energy based ablative treatments cryoablation followed by radio frequency ablation offers the most meaningful results, with promising local control rates indicated in some series. These methods can be performed less invasively than partial nephrectomy and require less surgical expertise. We anticipate that these modalities will be formalized into urological practice and serve as a single continuum of care, customized according to disease and surgical expertise.

Which Is the Real Gold Standard for Small-Volume Renal Tumors? Radical Nephrectomy versus Nephron-Sparing Surgery

BACKGROUND AND PURPOSE

Until recently, the gold standard for treatment of localized renal-cell carcinoma with a normal contralateral unit was deemed to be a formal radical nephrectomy. Advocates of nephron-sparing surgery have recently challenged this concept; we wished to evaluate the evidence to determine which treatment is objectively superior for patients with renal tumors up to 4 cm.

MATERIALS AND METHODS

MEDLINE, CANCERLIT, and EMBASE computer literature searches were performed to identify peer-reviewed papers pertaining to radical nephrectomy (RN), nephron-sparing surgery (NSS), or comparisons of these methods for tumors as large as 4 cm in maximum diameter. Review of the bibliographies of recovered articles and data in recent textbooks were used to supplement the computerized searches. There were a total of 797 cases in the RN group and 1211 in the NSS group. The parameters specifically evaluated were evidence of local recurrence, disease progression, and death within 33 months, this period being chosen primarily because it was the shortest follow-up in the studies evaluated. The data were then subjected to rigorous statistical analysis. Laparoscopic radical nephrectomy (LRN) and laparoscopic nephron-sparing surgery (LNSS) articles were also reviewed; however, current follow-up periods were considered too short to draw a statistically significant conclusion.

RESULTS

Disease-specific survival rates (P=0.001; Mann-Whitney test) as well as the incidence of metastases (P<0.05; Mann-Whitney test) were significantly better in the NSS group. The incidence of local recurrence (P=0.22; Mann-Whitney test) was not significantly different. It should be borne in mind that there are different follow-up periods for each study, and this may have had an impact on the results.

CONCLUSION

Nephron-sparing surgery seems to be as effective as RN in patients with renal cell tumours up to 4 cm, although only a large randomized controlled trial with long follow-up periods would provide a definite answer.

Laparoscopic Reconstructive Urology

PURPOSE

Although laparoscopy has emerged as a feasible and effective alternative for a majority of open ablative abdominopelvic urological procedures, minimally invasive reconstruction has come to the forefront only recently. We present the current state of the art of laparoscopic reconstructive urology.

MATERIALS AND METHODS

We conducted an extensive MEDLINE search of purely laparoscopic surgery from 1976 through 2002. Based on the results, we divide clinical reconstructive laparoscopic procedures into 2 broad categories-established and evolving. Each category is further classified according to the organ involved-adrenal and kidney, ureter (evolving only), bladder and prostate, and miscellaneous. Clinical procedures were considered established if our literature review revealed any report of more than 100 patients, or reports from at least 5 different centers greater than 20 patients each. If these criteria were not met, the procedure was considered clinically evolving.

RESULTS

Laparoscopic reconstructive procedures such as pyeloplasty, radical prostatectomy and orchiopexy have achieved clinically established status. Laparoscopic bladder neck suspension, although reported in a significant number of cases, remains controversial because of its contradictory reported long-term success rates. Multiple additional laparoscopic reconstructive procedures have been performed in fewer numbers clinically with promising results.

CONCLUSIONS

Until recently, urological laparoscopic surgery primarily focused on ablative procedures, with success. Building on this initial experience, advanced and sophisticated reconstructive procedures of considerable technical complexity are increasingly being performed purely laparoscopically. It is anticipated that in the future laparoscopic surgery could increasingly evolve into a preferred approach for advanced and sophisticated urological reconstruction.

Minimally invasive nephron-sparing surgery

Open partial nephrectomy, with its excellent 5- and 10-year oncologic follow-up data, is the gold standard against which all other nephron-sparing alternatives must be compared. The evolving minimally invasive nephron-sparing alternatives can essentially be divided into three categories: excision (laparoscopic partial nephrectomy), probe ablation (eg, cryotherapy, radiofrequency ablation), and noninvasive ablation (high-intensity focused ultrasound). A proposed algorithm for the evolving indications of minimally invasive nephron-sparing surgical options is presented in Fig. 23. Currently, by emulating the established techniques of open partial nephrectomy, laparoscopic partial nephrectomy has the most immediate clinical application and relevance. Emerging data support the efficacy and reproducibility of renal cryotherapy. Five-year follow-up data should be available in the near future. Although renal radiofrequency ablation has the potential to further minimize morbidity, serious concerns remain regarding the completeness of cancer cell kill and the reliability of intraoperative monitoring. Noninvasive technologic advancements such as high-intensity focused ultrasound have considerable potential for the future.

Laparoscopic radical versus partial nephrectomy: assessment of complications

PURPOSE

We evaluated the short-term morbidity and complications of laparoscopic radical nephrectomy (LRN) compared with laparoscopic partial nephrectomy (LPN).

MATERIALS AND METHODS

From May 1998 to May 2002, 114 patients were identified with a single unilateral sporadic renal tumor and a normal contralateral kidney. These individuals had undergone LRN (35) or LPN (79).

RESULTS

The LRN and LPN groups were analyzed for age, sex, American Society of Anesthesiologists score and body mass index. Mean tumor size in patients undergoing LRN and LPN was 2.8 +/- 1.2 (range 0.9 to 4.5) and 2.5 +/- 1.0 cm (range 1 to 4.5), respectively (p = 0.17). There were no differences between the 2 groups in terms of mean hospital stay, blood transfusion or surgical complications. There was no difference in mean preoperative and postoperative serum creatinine in patients in the LPN group. Mean postoperative serum creatinine was significantly higher than the mean preoperative level in patients in the LRN group (1.51 +/- 0.22 vs 1.18 +/- 0.37 mg/ml, range 0.6 to 2.4, p = 0.02). In each group 1 case was converted to open surgery due to bleeding.

CONCLUSIONS

LPN is associated with similar postoperative convalescence and complications compared with LRN. The increase in serum creatinine noted in patients undergoing radical extirpation supports the use of LPN when clinically indicated.

Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients

PURPOSE

Laparoscopic partial nephrectomy is an emerging minimally invasive, nephron sparing approach for renal cell carcinoma. We compared perioperative outcomes after laparoscopic and open nephron sparing surgery (NSS) for patients with a solitary renal tumor of 7 cm or less at a single institution.

MATERIALS AND METHODS

Since September 1999, 100 consecutive patients have undergone laparoscopic partial nephrectomy for a sporadic single renal tumor of 7 cm or less at our institution. A contemporary cohort of 100 consecutive patients with similar inclusion criteria have undergone open NSS since April 1998. Since our laparoscopic technique was based on our established open surgical principles, the 2 approaches were similar, including transient renal vascular control, sharp tumor excision in a bloodless field, pelvicaliceal repair when necessary, suture ligation of transected intrarenal blood vessels and suture repair of the renal parenchymal defect over a bolster. Demographic, intraoperative, postoperative and short-term followup data were retrospectively compared between the 2 groups.

RESULTS

Median tumor size was 2.8 cm in the laparoscopic group and 3.3 cm in the open group (p = 0.005). There were significantly more tumors greater than 4 cm in the open group (p <0.001). There were more patients with a solitary kidney in the open surgical group (p = 0.002). More patients in the open group underwent NSS for a malignant tumor (p = 002). Comparing the laparoscopic versus open groups, median surgical time was 3 vs 3.9 hours (p <0.001), blood loss was 125 vs 250 ml (p <0.001) and mean warm ischemia time was 27.8 vs 17.5 minutes (p <0.001), respectively. In the laparoscopic and open groups median analgesic requirement was 20.2 vs 252.5 mg morphine sulfate equivalents (p <0.001), hospital stay was 2 vs 5 days (p <0.001) and average convalescence was 4 vs 6 weeks (p <0.001). Median preoperative serum creatinine (1.0 vs 1.0 mg/dl, p = 0.52) and postoperative serum creatinine (1.1 vs 1.2 mg/dl, p = 0.65) were similar in the 2 groups. No kidney was lost due to warm ischemic injury. Three patients in the laparoscopic group had a positive surgical margin compared to none in the open groups (3% vs 0%, p = 0.1). Laparoscopic NSS was associated with a higher rate of major intraoperative complications (5% vs 0%, p = 0.02). There were no significant differences in overall postoperative complications, although renal/urological complications were more common in the laparoscopic group (11% vs 2%, p = 0.01).

CONCLUSIONS

Open surgical partial nephrectomy remains the established standard for nephron sparing treatment of renal tumors. When applied to small renal tumors, the laparoscopic approach is associated with longer warm renal ischemia time, more major intraoperative complications and more postoperative urological complications. Our data also suggest that more deliberate efforts to achieve a wider surgical margin are necessary with the laparoscopic approach. Nevertheless, our data suggest that laparoscopic NSS is emerging as an effective, minimally invasive therapeutic approach with respect to renal functional outcome with the additional advantages of decreased postoperative narcotic use, earlier hospital discharge and a more rapid convalescence. Continued efforts are required to develop laparoscopic renal hypothermia techniques and facilitate intrarenal suturing, while minimizing warm ischemia time.