Hand-assisted laparoscopic partial nephrectomy

Partial nephrectomy using radiofrequency incremental bipolar generator with multi electrode probe: experimental study in bench pig kidneys

BACKGROUND

The aim of this research project was the realization of an incremental bipolar radiofrequency generator with inline 4-electrode probe for partial renal resection without clamping of the vessels.

METHODS

The experimentation was carried out across two phases: the preliminary realization of a specific generator and an inline multielectrode probe for open surgery (Phase 1); system testing on 27 bench kidneys for a total of 47 partial resection (Phase 2). The parameters evaluated were: power level, generator automatisms, parenchymal coagulation times, needle caliber, thickness of the coagulated tissue "slice", charring, ergonomy, feasibility of the application of "bolster" stitches.

RESULTS

The analysis of the results referred to the homogeneity and thickness of coagulation, energy supply times with reference to the power level and caliber of the needles. The optimal results were obtained by using needles of 1.5 mm caliber at power level 5, and with coagulation times of 54 seconds for the first insertion and 30 seconds for the second.

CONCLUSIONS

The experimentation demonstrated that the apparatus, consisting of a generator named "LaparoNewPro" and fitted with a dedicated probe for open surgery, is able to carry out a coagulation of the line of resection of the renal parenchyma in a homogeneous manner, in short times, without tissue charring, and with the possibility of stitching both on coagulated tissue and the caliceal system. The generator automatism based on the flow of the current supplied by each electrode is reliable, and the cessation of energy supply coincides with optimal coagulation.

Hand-assisted laparoscopic partial nephrectomy by using an "open" device of microwave tissue coagulator

PURPOSE

In this article, we report our experience in using an "open" device of a microwave tissue coagulator (MTC), for the hand-assisted laparoscopic partial nephrectomy (HALPN), as a safer, more reproducible method.

PATIENTS AND METHODS

From July 2005, 5 patients with small, exophytic renal tumors underwent an HALPN. In this procedure, the surgeon used a surgical handpiece MTC, which was originally designed for an open surgical procedure, and introduced it into the abdominal cavity through the GelPort. (Applied Medical, Rancho Santa Margarita, CA). The direction and angle of the needle puncture was easily and precisely changed in a timely fashion, depending on the site of coagulation. After coagulation, the tumor was resected with laparoscopic scissors and blunt dissection without renal pedicle clamping.

RESULTS

HALPN was successfully performed in all cases without any open conversions. Estimated blood loss was <100 mL in all cases. There was no postoperative complication, such as urine leakage or loss of renal function.

CONCLUSIONS

We believe that this technique minimizes the risk of unexpected collateral thermal damage by appropriate needle puncture and can be performed easily by urologists. The small incision does not greatly diminish the benefit of minimally invasive surgery.

Efficacy of parenchymal compression in open partial nephrectomies: a comparison with conventional vascular clamping

Purpose

We evaluated the efficacy of parenchymal compression in open partial nephrectomies (OPNs) compared with that of the conventional vascular clamping method.

Materials and Methods

OPNs were conducted by means of the parenchymal compression technique at our institution from April 2006. Among these, the operative outcomes of 20 consecutive patients with normal preoperative renal function (Group 1) were matched with those of 20 control patients from the database of previous operations who underwent OPN with a conventional vascular clamping method (Group 2).

Results

All preoperative characteristics were similar in both groups. The operative time was significantly higher for Group 2 (132.4±17.7 vs. 151.4±21.4 minutes, p=0.031). Estimated blood loss was slightly higher for Group 2, with marginal statistical significance (173.7±11.5 vs. 211.2±43.8 ml, p=0.06). Histologic examination revealed that over 80% of the tumors in both groups were renal cell carcinomas. For all patients, the pathology results of specimens were negative. Serum creatinine, checked at 1, 3, and 7 days after the operation, was significantly increased in both groups to a similar degree. However, 30 days after surgery, the patterns of serial serum creatinine levels demonstrated statistically significant differences by repeated-measures ANOVA (p<0.001), with a trend of more elevated in Group 2 than in Group 1, although values were within the normal range. No major complications occurred in either group.

Conclusions

OPN using the parenchymal compression method had acceptable outcomes in terms of complete tumor control, avoiding warm ischemic time, and minimizing blooding, with good preservation of renal function and minimal complications.

Hand-assisted laparoscopic partial nephrectomy after 60 cases: comparison with open partial nephrectomy

BACKGROUND

Partial nephrectomy is the surgical standard of care for favorably located, small renal tumors. As the incidence of renal cell carcinoma (RCC) and detection of small kidney masses have increased over the past 20 years, minimally invasive management of these lesions has become more common. We report our single-institution experience with hand-assisted laparoscopic partial nephrectomy (HALPN) compared with open partial nephrectomy (OPN).

METHODS

Relevant outcome and demographic information was collected prospectively for HALPNs (N = 60) and retrospectively for OPNs (N = 40). A p-value of < 0.05 denotes statistical significance.

RESULTS

Average tumor size (2.6 cm HALPN versus 2.6 cm OPN, p = 0.97) was similar. Mean operative times were shorter for HALPN compared with OPN (161 versus 191 min, p = 0.027). HALPN was also associated with less blood loss (mean 120 cc versus 353 cc, p = 0.0003). Warm ischemia time was shorter for HALPN (mean 27.0 min versus 33.0 min, p = 0.035), as was hospital stay (mean 4.9 days versus 6.9 days, p = 0.007). Although four HALPN renal tumors required intraoperative margin re-excision (based on immediate gross evaluation by a pathologist), the final positive margin rate was 0%. A 5% final positive margin rate was observed in the OPN group. There were two conversions from HALPN to HAL radical nephrectomy and no conversions to an open technique. The HALPN minor complication rate was 18.3% versus 32.5% for OPN (p = 0.10). Complications included delayed bleeding (1, 2.5% OPN), urine leak (2, 5% OPN; 2, 3.3% HALPN), hypoxia, and nausea or fever lasting >3 days. Tumor pathology was as follows: 80.7% and 80% RCC, 12.3% and 8% oncocytoma, and 7% and 12% angiomyolipoma, for HALPN and OPN, respectively in each case.

CONCLUSIONS

HALPN is associated with diminished blood loss, operating time, warm ischemia time, positive margin rates, and length of stay compared with OPN. In our institution, HALPN is the standard approach for patients with small, surgically accessible renal tumors.

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.

Superselective Embolization as First Step of Laparoscopic Partial Nephrectomy

OBJECTIVES

Laparoscopic partial nephrectomy is currently very hard to perform because of the great difficulty in obtaining renal parenchymal hemostasis during tumor excision and the consequent high risk of bleeding. The aim of this study was to propose a method to decrease the risk of bleeding, consisting of the superselective embolization of tumor vessels before performing the laparoscopic partial nephrectomy.

METHODS

Fifty patients with small, solitary, enhancing, predominantly exophytic renal tumors underwent a superselective radiographically guided embolization of tumor vessels. An average of 6 hours after embolization, the patients underwent partial laparoscopic nephrectomy, with transperitoneal access and three trocars placed, under balanced general anesthesia. The mean operative time was measured, as was the mean estimated blood loss.

RESULTS

The mean operative time was 90 minutes, the mean estimated blood loss was 200 mL, and the average hospital stay was 6 days. Complications were reported in only 2 patients. The final pathologic evaluation confirmed the diagnosis of renal cell carcinoma in 43 cases. The median follow-up was 11 months and, to date, the examinations have revealed no recurrences in any of the cases.

CONCLUSIONS

Superselective embolization is a valid option for laparoscopic partial nephrectomy. The procedure does not require any regional vascular control or clamping, reduces the estimated blood loss, and reduces the operative time.

Evolving principles of surgical management and prognostic factors for outcome in renal cell carcinoma

The generally accepted principles for the surgical management of renal cell carcinoma (RCC) were first described more than 30 years ago. Since then, much has changed in the understanding of the basic biology and genetics of kidney cancer. Improvements in cross-sectional imaging has allowed for more accurate preoperative clinical staging of renal tumors, and the necessity of completing all the components of the radical nephrectomy have been questioned. Surgical techniques have also evolved, and technology has advanced to make possible new methods of managing renal tumors. The TNM staging system is currently the most extensively used system to provide prognostic information for RCC. However, data published in the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate and predictive prognostic factors. Furthermore, the recent discovery of molecular tumor markers are expected to revolutionize the staging of RCC and lead to the development of new therapies based on molecular targeting. This review will examine the evolving principles in the surgical management of RCC as well as provide an update on current staging modalities and prognostic factors.

Pneumothorax during argon beam-enhanced coagulation in laparoscopy

Argon beam coagulation is an effective modality to control rapid diffuse hemorrhage. We present a case of pneumothorax from argon beam coagulation used during laparoscopic surgery. We discuss potential cardiopulmonary consequences of this relatively new application of argon beam technology.

[Hand-assisted laparoscopic nephrectomy]

INTRODUCTION AND OBJECTIVES

To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy.

MATERIAL AND METHOD

Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery.

RESULTS

One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days

CONCLUSIONS

The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Long-term outcomes of the surgical management of renal cell carcinoma

It has been 35 years since the radical nephrectomy was standardized by the work of Robson et al. (J Urol 101:297-301, 1969). Despite being based on a retrospective review of only 88 cases operated upon over a span of 15 years, this publication was an important milestone in the attempt to create uniformity in the staging of Renal cell carcinoma (RCC), and the measurement of surgical outcomes for RCC. Although this manuscript forms the basis for our contemporary measurement of the long-term results of RCC surgery and set the standard to which the entire subsequent literature was compared, contemporary research subsequently has questioned many of Robson's conclusions regarding RCC. In Robson's era, the majority of patients presented with large, symptomatic tumors, pre-operative staging was imprecise, and many patients had locally advanced disease at the time of surgery: of the 88 patients in Robson's series, 75% were managed through a thoracoabdominal incision. Since that time, 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 have evolved and technological advances have made possible new methods of managing renal tumors in situ that have emphasized a transition from radical to less extirpative approaches. In addition, understanding of the basic biology and genetics of kidney cancer has led to improved prognostication and the development of effective immunotherapies for advanced disease. The current concepts and long-term outcomes of the surgical management of RCC will be reviewed to help elucidate some of these changes, from the evolution of open to laparoscopic to percutaneous, from radical to partial to ablative approaches.

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.

Practical usefulness of ultrasonic surgical aspirator with argon beam coagulation for hepatic parenchymal transection

The objective of this study was to evaluate the effectiveness and feasibility of using the Cavitron ultrasonic surgical aspirator (CUSA) with argon beam coagulation (ABC) during hepatic resection, in comparison with a conventional method using CUSA with bipolar cautery. Between April 2003 and March 2004, a series of 14 consecutive patients underwent hepatic resection of normal liver. Hepatectomies were performed using CUSA and bipolar irrigation electrocautery (BP) in eight patients between April 2003 and December 2003. CUSA and an ABC were used in six patients between January 2004 and March 2004. There were no differences in patient characteristics between the two groups. Blood loss per area of transected liver surface was significantly lower for CUSA with ABC than for CUSA with BP (2.9 +/- 1.44 vs. 6.33 +/- 3.14 ml/cm2). Furthermore, the speed of resection, defined as resection time per area of transected liver surface, was significantly greater for CUSA with ABC than for CUSA with BP (0.53 +/- 0.14 vs. 2.18 +/- 1.73 min/cm2). This new technique of combining CUSA with ABC can decrease blood loss during hepatic parenchymal transection and shorten the resection time.

Controlled Survival Study of the Effects of Tisseel or a Combination of FloSeal and Tisseel on Major Vascular Injury and Major Collecting-System Injury during Partial Nephrectomy in a Porcine Model

PURPOSE

We report the results of a controlled survival study in a porcine model investigating Tisseel or a combination of FloSeal and Tisseel in dealing with vascular and collecting-system injury during partial nephrectomy.

MATERIALS AND METHODS

We performed an open right lower-pole partial nephrectomy on 15 large female pigs. The defect was repaired using standard open techniques (N = 5; controls), Tisseel only (N = 6; group I), or FloSeal followed by Tisseel (N = 4; group II). A Jackson-Pratt drain was placed. Nephrectomy and retrograde pyelography were performed at 1 week.

RESULTS

Operative times were shorter in both study groups, achieving statistical significance in group I (P = 0.008). Warm-ischemia times were significantly improved in both study groups (P = 0.029 and P = 0.00005 in groups I and II, respectively). Time to hemostasis was significantly shorter in group II only (P = 0.002) but approached significance in Group I as well (P = 0.09). Estimated blood loss was not significantly different from the controls in either group. When Tisseel was placed alone after hilar control, hematoma formation under the Tisseel was noted on release of the hilar clamp. After 1 week, there was one urinoma and three urine leaks in the control group. In group I, there was one urinoma and four urine leaks, and there was only one urine leak and no urinomas in group II. There were no hematomas in any of the groups.

CONCLUSIONS

Tisseel alone is not adequate for either hemostasis or management of major collecting-system injury. FloSeal capped with Tisseel appears sufficient to control major vascular and collecting-system injuries without adjunctive surgical measures. A proposed technique for laparoscopic partial nephrectomy without reconstructive techniques is presented that warrants clinical study.

Hand-Assisted Retroperitoneoscopic Live Donor Nephrectomy: Experience from the First 75 Consecutive Cases

BACKGROUND

The two major life-threatening complications associated with laparoscopic live donor nephrectomy are sudden severe bleeding and intestinal injury. A combined technique-hand-assisted and retroperitoneoscopic (HARS)-reduces the risk of these life-threatening complications. In this study, we report on our experience from the first 75 consecutive HARS operations.

METHODS

The data has been collected prospectively according to intention to treat and includes all consecutive donors operated with the HARS technique. Warm ischemia time, operating time, and blood loss were recorded. Complications, convalescence, and allograft outcome were followed postoperatively with a mean follow-up of 701 (range 60-1438) days.

RESULTS

The mean operating time was 138 (range 85-260) minutes and the mean warm ischemia time 175 (85-510) seconds. The operative time was significantly longer in male donors. The mean bleeding was 176 (50-700) ml. There were no conversions to open surgery. Major complications comprised one pulmonary embolus and one donor required 2 units of blood transfusion. One donor was reoperated due to suspicion of trocar hernia. Nine patients experienced minor complications (fever, n=4; urinary tract infection, n=2; chylous ascites, n=1; orchialgia, n=1; subcostal pain, n=1). All except two kidneys had immediate onset of function. Neither of these could, however, be attributed to the donor operation. One recipient experienced urinary leakage and one a stenosis. Recipient and graft survival were 99% and 96%, respectively.

CONCLUSIONS

We conclude that HARS facilitates the procedure by enabling short operating times and at the same time significantly reducing the risks associated with endoscopic live donor nephrectomy.

Laparoscopic vs open partial nephrectomy in consecutive patients: the Cornell experience

OBJECTIVE

To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique.

PATIENTS AND METHODS

We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance.

RESULTS

Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed.

CONCLUSIONS

LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.

Technique for ensuring negative surgical margins during laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE

Obtaining a negative surgical margin during laparoscopic partial nephrectomy (LPN) is paramount to optimizing the oncologic efficacy of the procedure. Limitations of laparoscopy hinder the ability to extrapolate the intraparenchymal tumor extension from the exophytic portion. We developed a technique wherein ultrasound-confirmed needle localization of the deep tumor margin prior to tumor extirpation ensured negative surgical margins.

MATERIALS AND METHODS

Our technique was developed and initially tested using an agar-based ultrasound phantom designed to mimic 2-cm exophytic renal tumors. Needle placement was imaged with ultrasonography and subsequently correlated with findings on sectioning of the tumor mimic. Laparoscopic extirpation of the tumor mimic following needle placement was carried out in a pelvic trainer. The technique has subsequently been incorporated into our LPN technique in four patients.

RESULTS

Ultrasound-confirmed needle localization of intraparenchymal tumor extension was feasible and reproducible in an ultrasound phantom. Ultrasound findings correlated with gross findings. Needle placement prior to tumor resection helped to ensure negative surgical margins when applied in the pelvic trainer and when used in three patients. In the remaining patient, improper needle placement resulted in a grossly positive deep margin.

CONCLUSION

Ultrasound-confirmed needle placement effectively and reproducibly marks the deep margin of small renal tumors in a mimic as well as in vivo. Our needle technique eliminates the guesswork and unreliability associated with mental visualization and extrapolation of tumor extent during LPN.

Partial Laparoscopic Nephrectomy Using Monopolar Saline-Coupled Radiofrequency Device: Animal Model and Tissue Effect Characterization

BACKGROUND AND PURPOSE

The optimal surgical tool for laparoscopic partial nephrectomy (LPN) would permit resection of lesions that penetrate relatively deeply and achieve hemostasis while allowing accurate viewing of the margins of the lesion, identification of the collecting system, control of both arteries and veins, and sealing of the collecting system. We hypothesized that the TissueLink Floating Ball (TissueLink, Inc.) might provide a simple, "pure" method of LPN.

MATERIALS AND METHODS

Ten adult female pigs (30-50 kg) underwent LPN of the left kidney with the TissueLink operating at 70 to 80 W as the sole means of hemostasis. Operative time, estimated blood loss (EBL), and specimen weight and characteristics, were recorded. On postoperative day 7, an intravenous urogram was carried out, and an open partial nephrectomy and surface treatment were performed on the other side with the TissueLink and intraparenchymal temperature monitoring.

RESULTS

All LPNs were performed without complications with an average operating time of 148 minutes and a mean estimated blood loss of 49 mL. The urograms performed at postoperative day 7 demonstrated prompt excretion and no evidence of urinary extravasation or hydronephrosis. At harvest, all eight kidneys in which the collecting system had been entered showed evidence of localized urine leak. No evidence of retroperitoneal hematoma was noted, and all renal arteries and veins were patent and with good flow. The resected edge showed a gross 2 to 3 mm of flat, whitish discoloration and a well-demarcated edge. During the open partial nephrectomy, significant temperature variations were noted according to the distance from the point of application of the TissueLink. Pathologic examination of the acute specimens demonstrated altered cytoplasmic and nuclear staining in tubules extending approximately 6 to 8 mm from the treated surface. In contrast, the kidney that had been left in situ after LPN demonstrated overt cortical necrosis (coagulated necrosis), bordered by cortical scarring with apparent dystrophic calcifications at the resection edge from the previous partial nephrectomy. Tubular atrophy was obvious, with interstitial fibrosis and interstitial inflammation. A well-demarcated zone of several millimeters of tissue was evident on gross examination.

CONCLUSIONS

The saline-cooled monopolar radiofrequency dissector (TissueLink) is a valuable adjunct for LPN. The device provided excellent hemostatic control with resection of as much as 40% of the renal parenchyma. Our initial observations of the device in the laboratory and in clinical use led us to develop a successful technique for its use for deep parenchymal resection, which is described in detail.

Laparoscopic Partial Nephrectomy: Hand-Assisted Technique

Laparoscopic partial nephrectomy (LPN) is a challenging procedure that has become more popular as techniques have evolved and made the procedure more standardized. We present our hand-assisted technique for LPN. In order to meet the challenges of larger, deeper lesions and to address complications, our technique has evolved from pure hand assistance to hand assistance with hilar clamping and hemostatic adjuncts. We discuss patient selection, preparation and access, renal exposure, preparation of hemostatic agents, resection of the mass, hemostasis, and closure. The results of 76 hand-assisted LPNs (HALPNs) are summarized. While our technique will undoubtedly continue to evolve, HALPN appears to be safe and effective for minimally invasive nephron-sparing surgery.

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: Technique, oncologic efficacy, and safety

Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses, but has been performed with significant variability in technique. The procedure's evolution, a merger of proven open techniques with applicable laparoscopic techniques and limitations, is very much a work in progress. Just as long-term follow-up for open nephron-sparing surgery for selected renal masses has demonstrated recurrence-free survival equivalent to radical nephrectomy, a few large series of laparoscopic partial nephrectomy are beginning to surface that demonstrate its clinical efficacy, although duration of follow-up is still too short to make definitive statements. This article reviews the literature and the authors share their experience and preferences in technique, derived from 100 consecutive laparoscopic partial nephrectomies and from their assessment of the acute sealant effectiveness for partial nephrectomy in a large, hypertensive, porcine model that approximates clinical situations. This review aims to assist the urologic surgeon in determining which renal tumors to approach laparoscopically and which surgical approach best fits their laparoscopic expertise.

ELIMINATING KNOT TYING DURING WARM ISCHEMIA TIME FOR LAPAROSCOPIC PARTIAL NEPHRECTOMY

PURPOSE

Rapid intracorporeal suturing represents a challenge when performing laparoscopic partial nephrectomy (LPN). During warm ischemia time (WIT) knot tying is a major time-consuming step. We present our technique of eliminating knot tying during LPN and the outcomes of our initial series.

MATERIALS AND METHODS

Between October 2002 and October 2003, 32 patients underwent LPN for clinical T1a renal tumors. Our technique includes initial placement of a 5Fr ureteral catheter for collecting system irrigation. The renal hilum is clamped, the tumor is sharply excised and freehand suturing of the collecting system and renal parenchyma is performed using 2-zero and zero polyglactin sutures prepared with an absorbable clip (LapraTy, Ethicon Endosurgery Inc., Piscataway, New Jersey) at the terminal end. Once the suture is passed an additional clip is used to cinch it down, obviating the need for knot tying. This technique is used for closure of the collecting system as well as for placement of parenchymal compressive sutures over bolsters. Subsequent testing for watertightness with methylene blue solution is performed.

RESULTS

Pathological mean tumor size was 2.1 cm (range 0.3 to 4.2). Mean operative time was 224.2 minutes (range 105 to 396). In 21 cases (65.6%) the collecting system was entered, necessitating further suturing. Mean WIT was 33.1 minutes (range 13 to 55) and mean estimated blood loss was 222.7 cc (range 5 to 600). No postoperative bleeding or urine leaks were encountered in this series.

CONCLUSIONS

The use of LapraTy clips as an alternative to knot tying in LPN is safe and efficient. It simplifies the procedure and allows completion of the necessary suturing tasks during an acceptable WIT.

LAPAROSCOPIC PARTIAL NEPHRECTOMY TECHNIQUES: DEVELOPMENTS AND TRANSLATION

PURPOSE

Laparoscopic partial nephrectomy has recently emerged as a potential surgical option for select renal masses. Several new techniques and devices that may aid in laparoscopic partial nephrectomy are reviewed.

MATERIALS AND METHODS

I review several techniques studied and/or developed in our laboratory. Each technique was evaluated for effectiveness in the porcine model and is in translation to clinical practice.

RESULTS

Three techniques are reviewed. A hand assisted approach incorporating renal hilar clamping with hypothermia has proven successful for complex and multifocal lesions. Recent clinical studies, and our laboratory and clinical experience have shown a saline cooled monopolar dissector to be a valuable adjunct. A new and simple technique of achieving rapid hypothermia using a pure laparoscopic approach is described.

CONCLUSIONS

Laparoscopic partial nephrectomy continues to develop as a standard of care for select renal masses. New devices and techniques will continue to make the procedure safer and reproducible.

Hand-Assisted Laparoscopic Partial Nephrectomy without Hilar Vascular Clamping Using a Saline-Cooled, High-Density Monopolar Radiofrequency Device

BACKGROUND AND PURPOSE

Nephron-sparing surgery is now accepted as an alternative treatment option for small renal tumors. However, hemostasis during laparoscopic partial nephrectomy can be technically challenging, especially without hilar vascular clamping. The aim of our study was to evaluate the technique of hand-assisted laparoscopic partial nephrectomy using the TissueLink (TissueLink Medical, Dover, NH), a saline-cooled monopolar radiofrequency device, without hilar vascular clamping.

PATIENTS AND METHODS

Using the hand-assisted laparoscopic approach, the kidney is mobilized transperitoneally, and the renal tumor with overlying perinephric fat is exposed. The tumor is excised with a 1-cm margin using a combination of the TissueLink device and endoscopic scissors. The tumor and a biopsy of the base of the tumor bed are sent for frozen-section examination. The bleeding vessels are controlled with digital compression and the TissueLink device. At the end of procedure, the tumor bed is covered with a hemostatic agent. Three female and four male patients ages 52 to 76 years (mean 66 years) were treated with this new device for incidental tumors detected during imaging studies (N = 6) or during work-up for gross hematuria (N = 1). Preoperative imaging studies included CT in six patients and MRI in three. The average tumor size was 2.2 cm (range 1.3-3 cm). Only peripheral tumors that did not approach the hilum or the collecting system were selected.

RESULTS

All of the patients underwent a hand-assisted laparoscopic partial nephrectomy using the TissueLink device without hilar vascular clamping. There were no intraoperative complications or conversions to open surgery. The mean operative time was 175 minutes, with an estimated blood loss of 186 mL (range 100-300 mL). Histologic examination demonstrated renal-cell carcinoma in five cases, oncocytoma in one, and an angiomyolipoma in one. The dimensions of the normal tissue around the tumor ranged from 1 to 4 mm, and frozen-section analysis showed tumor-free margins in all cases. Postoperatively, all patients recovered well except one patient who developed transient atrial fibrillation, which was treated medically in the immediate postoperative period. All patients were discharged in good condition at an average of 3 days (range 2-6 days).

CONCLUSION

Hand-assisted laparoscopic partial nephrectomy without vascular clamping using the TissueLink device is a safe and feasible technique for exclusion of small exophytic renal tissues.

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.

Hand-Assisted Laparoscopic Devices: The Second Generation

BACKGROUND AND PURPOSE

Hand-assisted laparoscopic (HAL) nephrectomy is an increasingly popular surgical modality. Within the last year, three newly designed second-generation hand-assist devices have emerged with the intention to improve efficacy and ease of use. We prospectively evaluated and compared these with each other and with the first-generation devices.

MATERIALS AND METHODS

A total of 130 urologists performed two HAL nephrectomies in a porcine laboratory using two different hand devices at an American Urological Association-sponsored learning course. Sixty-three urologists utilized the second-generation devices (Gelport, Omniport, LapDisc), while 67 urologists used the first-generation devices (Handport, Intromit, PneumoSleeve). Each surgeon completed a 12-question survey evaluating the devices.

RESULTS

Evaluation of the second-generation devices revealed that Gelport was statistically significantly superior in all parameters to the Omniport and in 5 of 10 parameters to the LapDisc. Comparison of the first- and second-generation devices revealed that only the Gelport achieved a significant increase in all ratings. Among the first-generation devices, no device scored better than 8.27 of 10 in any category. Analysis of the second-generation devices demonstrated that the Gelport scored a rating above 8.25 in all parameters with an overall satisfaction score of 8.59. Both the Omniport and the LapDisc attained ratings comparable to those of the first-generation devices.

CONCLUSION

The HAL procedure relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The Gelport, when evaluated in a porcine model by training laparoscopic urologists, appears to be significantly better than other devices available to date. Further testing with larger cohorts and human clinical trials are required to confirm these findings.

Partial nephrectomy with fibrin glue repair: measurement of vascular and pelvicaliceal hydrodynamic bond integrity in a live and abbatoir porcine model

PURPOSE

Some of the challenges during partial nephrectomy include control of bleeding and repair of the pelvicaliceal system. Fibrin tissue sealants have recently been used to achieve hemostasis and collecting system closure in open and laparoscopic partial nephrectomy. However, there exist little data regarding the intrinsic strength of the bond, especially when applied to the vasculature and the urinary collecting system of the transected kidney. We examined the hydrodynamic bond integrity of a commercially available fibrin tissue sealant in a live porcine animal model undergoing partial nephrectomy.

MATERIALS AND METHODS

Open partial nephrectomy was performed in 19 porcine renal units. Collecting system entry was confirmed by methylene blue instillation into the proximal ureter. Fibrin tissue sealant was used to repair 16 renal units, that is 8 kidneys hardened in vivo for 10 minutes and 8 hardened in vivo for 60 minutes. In an additional 3 renal units monopolar electrocautery was used to achieve hemostasis (no fibrin glue used). The strength of vasculature repair was performed by infusing saline into the renal artery (renal vein ligated) and measuring pressure at bond rupture. Similarly the integrity of pelvicaliceal repair was evaluated by retrograde infusion of saline into the collecting system via the proximal ureter and measurement of pressure at bond rupture.

RESULTS

Fibrin tissue sealant was successful in achieving prompt hemostasis and it was subjectively superior to cautery alone with regard to bleeding control. Mean renal vascular and pelvicaliceal burst pressure for fibrin sealant treated kidneys was 378 (median 420) and 166 mm Hg (median 170), respectively. There was no significant difference in 10 vs 60-minute hardening times in treated kidneys. In comparison, vascular and pelvicaliceal burst pressure for nontreated (cautery alone) kidneys was 230 (median 220) and 87 mm Hg (median 90), respectively.

CONCLUSIONS

Commercially available fibrin tissue sealants can provide supraphysiological renal parenchyma and collecting system sealing pressures after partial nephrectomy. This information supports the potential use of fibrin sealants during open and laparoscopic partial nephrectomy.

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.

Hand-Assisted Laparoscopic Partial Nephrectomy

The resurgence of nephron-sparing surgery for selected renal masses has fueled interest in minimally invasive approaches. Several authors have shown that laparoscopic partial nephrectomy is feasible if two goals are met: resection of the mass with negative margins and control of bleeding. The latter is a particular challenge, but numerous options are available. The authors describe the operative technique and the available results of hand-assisted laparoscopic partial nephrectomy.

Trocar Arrangement for HALS

The appropriate position of the hand-access device and trocars for hand-assisted laparoscopic surgery depends on several factors, including the surgeon's preference, physical stature, and handedness; the patient's anatomy; and the type of procedure being performed. This article reviews the options, including measures for special circumstances such as patient obesity.

Prospective experience with a second-generation hand-assisted laparoscopic device and comparison with first-generation devices

BACKGROUND AND PURPOSE

The GelPort Hand-Assisted Laparoscopy (HAL) device was licensed for use in the U.K. in September 2001. We compared our experience with this second-generation device with that of first-generation devices; i.e., the Handport, launched in 1999, and the Intromit, first marketed in 1998.

MATERIALS AND METHODS

We prospectively compared a number of parameters for operations performed using the GelPort (13 radical nephrectomies, 4 nephroureterectomies) with those performed using the Handport (3 radical nephrectomies, 2 nephroureterectomies, 2 simple nephrectomies) and the Intromit (2 radical nephrectomies, 1 nephroureterectomy, 2 simple nephrectomies). The main outcome measures were ease of application, time required to place the device, and perioperative complications specific to the device.

RESULTS

The device requiring the longest time to place was the Intromit (average 15 minutes) followed by the HandPort (average 10 minutes) and then the GelPort (average 5 minutes). There were two leaks with the Intromit (one major and one minor). Pop-outs were a frequent issue with the HandPort, necessitating repeated replacement and resufflation. There was also a need to resufflate every time the hand was removed for a change of swab. None of these problems was noted with the GelPort, which was also found to be the easiest to use. The major disadvantage of the GelPort was its price, which was about a third more than that of the first-generation devices.

CONCLUSION

The GelPort is currently a more user-friendly and robust HAL device. It is, however, more expensive than first-generation devices.

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.

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.

Laparoscopic partial nephrectomy with temporary arterial occlusion: description of technique and renal functional outcomes

OBJECTIVES

To report our laparoscopic partial nephrectomy experience and the impact of temporary arterial occlusion during laparoscopic partial nephrectomy on postoperative renal function. Laparoscopic partial nephrectomy is increasingly popular but remains technically challenging.

METHODS

Laparoscopic partial nephrectomy was performed in 27 patients, with arterial occlusion in 15 cases. Postoperative renal function was evaluated with serum creatinine in all patients and postoperative technetium-99m mercaptoacetyl triglycine renal scans in a subset of patients after arterial occlusion.

RESULTS

The group with arterial occlusion (n = 15) did not differ from those without arterial occlusion (n = 12) with respect to age, body mass index, American Society of Anesthesiologists score, lesion size, operative time, blood loss, or complications. In patients undergoing arterial occlusion, the mean warm ischemia time was 43 +/- 10 minutes (range 25 to 65). The preoperative and postoperative serum creatinine levels were unchanged in patients with (1.07 +/- 0.4 to 1.15 +/- 0.4 ng/dL; P = 0.24) and without (0.96 +/- 0.22 to 1.07 +/- 0.27 ng/dL; P = 0.14) arterial occlusion. The tumor size on imaging correlated with postoperative serum creatinine (r2 = 0.450, P = 0.04). Nuclear renography was performed in 9 patients (60%) after renal artery occlusion. The mean differential renal function of the operated kidney (49%) was similar to that of the contralateral kidney (51%) and was not associated with warm ischemic time or tumor size.

CONCLUSIONS

Temporary arterial occlusion during laparoscopic partial nephrectomy does not appear to affect short-term renal function adversely. We believe that this technique can be safely performed when significant bleeding or entry into the collecting system is anticipated. Additional study is warranted to identify the maximal time of warm ischemia and ways to reduce potential renal injury.

Bipolar needle electrocautery for laparoscopic partial nephrectomy without renal vascular occlusion in a porcine model

OBJECTIVES

To report a novel method of accomplishing laparoscopic lower pole partial nephrectomy in an acute porcine model using a bipolar needle electrode without the need for renal arterial occlusion.

METHODS

Six animals (12 renal units) underwent laparoscopic polar nephrectomy using the bipolar needle electrode. After complete laparoscopic mobilization of the lower pole of the kidney, the bipolar needle electrode was repeatedly inserted full-thickness into the renal parenchyma and applied transversely, creating regional ischemia to the entire lower pole without renal vascular occlusion. The specimen was then amputated using laparoscopic scissors.

RESULTS

For the 12 laparoscopic partial nephrectomies, the mean operative time was 39 +/- 30 minutes, and the mean blood loss was 90 +/- 112 mL. Of the 12 cases, 10 (83%) were performed successfully with the bipolar needle electrocautery as the only source of hemostasis and without the need for ancillary hemostatic measures. Two of the procedures (17%) required temporary arterial control for hemostasis. For the successful procedures, the mean operative time was 29 +/- 4 minutes, and the mean blood loss was 48 +/- 11 mL. Histologic analysis of the specimens demonstrated coagulative necrosis between 2 and 4 mm from the line of the surgical incision.

CONCLUSIONS

Bipolar needle electrocautery is a promising device that can be used to facilitate laparoscopic partial nephrectomy with minimal blood loss and without the need for renal arterial occlusion and warm ischemia. Additional studies are required to optimize the delivery parameters of this device.

Hand-Assisted Surgery Improves Outcomes for Laparoscopic Nephrectomy

Laparoscopy has become the preferred method for nephrectomy in many medical centers. We compared our experience with hand-assisted laparoscopic nephrectomy (HALN) and standard laparoscopic nephrectomy (LN). Data were prospectively collected on 119 consecutive patients undergoing laparoscopic nephrectomy between August 2000 and November 2002. Outcomes were compared for LN versus HALN using Wilcoxon rank sum test for quantitative outcomes and Fisher exact test and x2 for qualitative outcomes. Thirty-nine patients underwent LN: 16 live donor, 16 radical, and 7 simple nephrectomies. Eighty patients were treated with HALN: 47 live donor, 32 radical, and 1 simple nephrectomy. There were no differences in mean age (49.2 years LN vs. 47.7 years HALN, P = 0.60) or weight (192.2 lb LN, 179.2 lb HALN, P = 0.12). Mean tumor size (4.77 cm LN vs. 7.12 cm HALN, P = 0.07) and length of extraction incision (8.37 cm LN vs. 7.87 cm HALN, P = 0.08) were similar. Total hospital charges ($19,352 vs. $18,505, P = 0.29) and length of stay (3.68 days vs. 3.72 days, P = 0.15) were equivalent for LN and HALN. Average operative time for HALN was significantly shorter (202 minutes vs. 258 minutes, P = 0.0001), and blood loss was less for HALN (71.7 cc vs. 113.1 cc, P = 0.007). Wound complications rates were similar (6.5% HALN vs. 13% LN, P = 0.34), but overall morbidity rates were higher after LN (28.2% vs. 6.3%, P = 0.001). Compared with pure laparoscopic nephrectomy, the hand-assisted approach reduces operative time and blood loss without increasing total hospital charges or length of stay. In our patients, HALN was also associated with fewer postoperative complications than standard laparoscopic nephrectomy. Hand-assisted laparoscopy may allow for the performance of increasingly complex procedures while maintaining the benefits of minimally invasive surgery.

Surgical treatment of renal neoplasia: evolving toward a laparoscopic standard of care

OBJECTIVES

To determine the extent to which laparoscopy has replaced open surgery for renal malignancy.

METHODS

The records of all 537 patients at Washington University who underwent surgery for localized renal malignancies from January 1997 to December 2001 were examined for clinical and pathologic information.

RESULTS

The total procedures per year increased from 1997 to 2001, but the distribution of pathologic stages throughout the 5 years was similar. In 1997, laparoscopic approaches were used in 15% of cases; this increased to 65% by 2001. Nephron-sparing surgery (NSS) was used in 31% to 42% of patients yearly, but laparoscopic NSS increased in frequency. By 2001, only 3.3% of T1 tumors were removed by open radical nephrectomy compared with 55% treated by laparoscopic nephrectomy. The rest of the T1 tumors in 2001 were treated by open partial nephrectomy (20.2%) or laparoscopic NSS (21.3%). In 2001, 61% of T2 lesions were treated laparoscopically, an increase from 37% in 1997. Most open radical nephrectomies in 2001 were performed for T3 disease. The number of surgeons performing laparoscopic renal surgery has increased at our institution, from two in 1997, both endourologists, to eight in 2001, representing the entire urology faculty that treats renal cancer.

CONCLUSIONS

Laparoscopic radical nephrectomy has replaced open radical nephrectomy for low-stage renal neoplasia. Although laparoscopic NSS is increasing in frequency, it has not yet replaced open partial nephrectomy. At our institution, the laparoscopic approach has become the standard of care when radical nephrectomy is needed for T1 or T2 renal cancer.

Use of Fibrin Glue and Gelfoam to Repair Collecting System Injuries in a Porcine Model: Implications for the Technique of Laparoscopic Partial Nephrectomy

BACKGROUND AND PURPOSE

One of the challenges of laparoscopic partial nephrectomies is the repair of a collecting system injury. We hypothesized that fibrin glue plus Gelfoam could be sufficient to repair such injuries.

MATERIALS AND METHODS

Four pigs (eight kidneys) underwent collecting system injuries of various lengths (3, 5, and 10 mm) (N = 8 each) during partial nephrectomy. Gelfoam soaked in the fibrin glue was applied to seal the collecting system and parenchymal defects. After 1 hour of passive filling, the renal pelvis was distended at supraphysiologic pressure to the point of leakage. Each repair site was examined for urinary extravasation during the physiologic and active phases of filling.

RESULTS

Hemostasis was achieved, and all collecting system injuries, regardless of size, were free of urinary leakage at physiologic pressures. Moreover, all defects maintained a seal at supraphysiologic pressures of at least 50 cm H(2)O.

CONCLUSION

The combined use of fibrin glue and Gelfoam is an effective means to obtain hemostasis and seal collecting system injuries up to 10 mm at physiologic pressures and up to 50 cm H(2)O in the acute setting. Our hope is that this technique can facilitate both laparoscopic and open partial nephrectomies. New technologies will be employed in an attempt to obtain better seating of the sealant plug in the future. Survival studies are in progress.

The role of partial nephrectomy for renal cell carcinoma in contemporary practice

Partial nephrectomy has proved to be a safe and effective treatment modality, even for patients with normal contralateral kidneys. The indications for elective partial nephrectomy continue to evolve as contemporary series demonstrate low morbidity approaching that of radical nephrectomy. Furthermore, patients who undergo partial nephrectomy have a significantly decreased risk of future renal insufficiency. As such, a rationale exists for expanding indications in an era of excellent technical outcomes and increased patient longevity. Characterization of newer diagnostic (three-dimensional imaging) and treatment (laparoscopic partial nephrectomy, cryosurgery) modalities will allow continued evolution of nephron-sparing techniques.

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.

Mayo Clinic Scottsdale experience with laparoscopic nephron sparing surgery for renal tumors

PURPOSE

Nephron sparing surgery is an accepted treatment for small renal masses, of which many have been detected incidentally due to the widespread use of advanced imaging techniques. We report our experience with laparoscopic nephron sparing surgery.

MATERIALS AND METHODS

From May 2000 to May 2002 a total of 20 laparoscopic partial nephrectomies were performed in 19 patients. The kidney was mobilized to allow adequate dissection, hemostasis and inspection of the kidney. Cautery, a harmonic scalpel and a TissueLink (TissueLink Medical, Inc., Dover, New Hampshire) device were variably used for dissection and hemostasis. Further hemostasis was then achieved using an argon beam laser with Fibrillar (Fibrillar Ethicon, Somerville, New Jersey), fibrin glue or the TissueLink device. Intact removal and biopsy of the lesion base were done to assess margin status.

RESULTS

Mean patient age was 66 years (range 41 to 80). Mean tumor size was 2.1 cm. (range 1 to 7) and average operative time was 130 minutes (range 60 to 210). Mean hospital stay was 2.2 days. Mean estimated blood loss was 120 ml. (range 20 to 400) and no blood transfusions or conversions to an open procedure were required. Complications included intraoperative fragmentation of a tumor in 1 case, postoperative dyspnea, postoperative bleeding and pneumonia in 1.

CONCLUSIONS

Laparoscopic partial nephrectomy for small renal tumors was performed safely and effectively. Technique depended on the size and location of the mass. Long-term followup is required to compare cancer control with that of open nephron sparing surgery.

Feasibility of laparoscopic partial nephrectomy using pledgeted compression sutures for hemostasis

PURPOSE

To develop a technique for laparoscopic partial nephrectomy (LPN) without the use of hilar occlusion that allows large renal resection and excellent hemostasis.

MATERIALS AND METHODS

Five female domestic pigs underwent right laparoscopic transperitoneal lower-pole partial nephrectomy after placement of pledgeted parenchymal compression sutures tied intracorporeally to induce regional renal hypoperfusion. Postoperatively, serial serum creatinine measurements were obtained to monitor renal function. The pigs were allowed to recover and 2 weeks later underwent an identical procedure on the left side. The animals were sacrificed after the second procedure, and both renal units were removed for ex vivo retrograde urograms and histologic analysis.

RESULTS

The median operative time was 154.5 minutes (range 110-305 minutes), and the median blood loss was 137.5 mL (range 100-300 mL). On average, 35% (range 31%-36.8%) of the kidney was resected. All cases required use of adjunctive hemostatic clips to control bleeding from central vessels. All animals survived 2 weeks and had no evidence of urinary extravasation clinically or on ex vivo retrograde urograms.

CONCLUSIONS

In the porcine model, LPN with placement of pledgeted sutures allows resection of large renal segments, although technical refinements are required to improve hemostasis. Currently, the need for adjunctive hemostatic measures limits the initial clinical application of this technique to small, exophytic tumors.

Prevention of pleural effusion following hepatectomy using argon beam coagulation

BACKGROUND

Postoperative pleural effusion occurs frequently after hepatectomy. The value of the argon beam coagulator (ABC) for the prevention of pleural effusion after hepatectomy in patients with hepatocellular carcinoma was studied.

METHODS

Sixty patients were divided randomly into two groups: an ABC group (n = 28), in which the cut surface of the hepatic ligaments and bare area of the retroperitoneum were cauterized using an ABC, and a control group (n = 32) in which the ABC was not applied. Patient characteristics, preoperative and postoperative liver function, and postoperative pleural effusion were compared between the two groups.

RESULTS

There were no significant differences between the two groups with respect to histological findings, clinical stage, type of resection, operative data, and preoperative and postoperative laboratory data. One of 28 patients in the ABC group and nine of 32 patients in the control group had pleural effusion. The incidence was significantly lower in the ABC group than in the control group (P = 0.01). Pleurocentesis was needed in two of the ten patients and thoracic drainage in four patients.

CONCLUSION

Application of an ABC to the cut surface of the hepatic ligaments and bare area of retroperitoneum after liver mobilization may prevent postoperative pleural effusion.

Laparoscopic partial nephrectomy and minimally invasive nephron-sparing surgery

Surgical extirpation remains the most effective therapy for renal cell carcinoma. The surgical management of renal masses has evolved away from radical nephrectomy and now includes nephron-sparing surgery for small tumors. Nephron-sparing surgery has similar cure rates and does not appear to compromise cancer control. As the detection of small renal masses by widespread abdominal imaging continues to increase, so will the demand for minimally invasive nephron-sparing procedures. Despite progress in surgical techniques, laparoscopic partial nephrectomy remains a technically challenging procedure. In this review, we discuss the challenges and recent advances in laparoscopic partial nephrectomy and other minimally invasive approaches to renal masses.